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Hodgkin's lymphoma (HL)-associated vanishing bile duct syndrome (VBDS) is a paraneoplastic phenomenon leading to cholestasis, end-stage liver failure and potentially death, due to cholestatic liver dysfunction typically precluding the commencement of curative intent chemotherapy. A female in her 20s presented with pruritus, jaundice and cholestatic hepatitis on laboratory tests, confirmed as VBDS on liver biopsy. CT of the chest demonstrated a mediastinal mass and widespread cervical lymphadenopathy. The patient received 30.6 Gy in 17 fractions to the involved sites of disease which led to a marked improvement in liver function, allowing curative intent chemotherapy to be initiated. The patient achieved complete metabolic response and at the most recent follow-up she had no signs of recurrent disease and near-normal liver function tests. This demonstrates that tumour-directed radiotherapy can be used as a potential bridge to curative chemotherapy in early stage HL-associated VBDS., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Ischemic cholangiopathy (IC) is the leading cause of inferior long-term outcomes following donation after circulatory death (DCD) liver transplant. Biliary strictures related to IC are nonanastomotic strictures (NASs) by definition and involve the donor hepatic ducts proximal to the anastomosis, compared with postsurgical anastomotic strictures that form due to fibrotic healing. IC-related NASs can be microangiopathic with patent hepatic artery or macroangiopathic with occluded or stenotic hepatic artery. Recently, IC with NASs have been described to have four distinct patterns at imaging: diffuse necrosis, multifocal progressive, confluence dominant, and minor form, which correlate clinically with graft prognosis. Severe IC can lead to ductal wall breakdown with subsequent bile leaks that can cause significant patient morbidity, with imaging playing a vital role in diagnosis and guiding intervention. IC also predisposes the transplanted liver to biliary stasis and subsequent formation of stones, casts, and sludge. Some cases of posttransplant biliary stricturing are not IC but are a sequela of reflux cholangitis seen with choledochojejunal anastomosis. Other biliary findings in the posttransplant liver can be explained by sphincter of Oddi dysfunction that results from denervation. The authors describe and comprehensively categorize the various IC types and their imaging patterns at MRI and MR cholangiopancreatography, review the prognostic significance of these imaging patterns, and discuss imaging features of additional biliary complications associated with IC after DCD liver transplant. © RSNA, 2024 Supplemental material is available for this article.

Several diseases originate from bile duct pathology. Despite studies on these diseases, certain etiologies of some of them still cannot be concluded. The most common disease of the bile duct in newborns is biliary atresia, whose prognosis varies according to the age of surgical correction. Other diseases such as Alagille syndrome, inspissated bile duct syndrome, and choledochal cysts are also time-sensitive because they can cause severe liver damage due to obstruction. The majority of these diseases present with cholestatic jaundice in the newborn or infant period, which is quite difficult to differentiate regarding clinical acumen and initial investigations. Intraoperative cholangiography is potentially necessary to make an accurate diagnosis, and further treatment will be performed synchronously or planned as findings suggest. This article provides a concise review of bile duct diseases, with interesting cases., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) is a surgical method used to treat benign and low-grade malignant pancreatic head tumors. This study aimed to determine the protective effect of common bile duct in LDPPHR using indocyanine green (ICG) fluorescence imaging., Methods: A retrospective analysis of 30 patients treated with LDPPHR at the Second Affiliated Hospital of Nanchang University between January 2015 and November 2022 was performed. Patients were divided into two groups based on ICG use: ICG and non-ICG., Results: Thirty patients received LDPPHR, 11 males and 19 females, and the age was 50.50 (M (IQR)) years (range: 19-76 years). LDPPHR was successfully performed in 27 (90 %) patients, LPD was performed in 1 (3 %) patient, and laparotomy conversion was performed in 2 (7 %) patients. One patient (3 %) died 21 days after surgery. The incidence of intraoperative bile duct injury in the ICG group was lower than that in the non-ICG group (10 % vs 60 %, P = 0.009), and the operation time in the ICG group was shorter than that in the non-ICG group (311.9 ± 14.97 vs 338.05 ± 18.75 min, P < 0.05). Postoperative pancreatic fistula occurred in 16 patients (53 %), including 10 with biochemical leakage (62.5 %), four with grade B (25 %), and two with grade C (12.5 %). Postoperative bile leakage occurred in four patients (13 %)., Conclusions: The ICG fluorescence imaging technology in LDPPHR helps protect the integrity of the common bile duct and reduce the occurrence of intraoperative bile duct injury, postoperative bile leakage, and bile duct stenosis., Competing Interests: Declaration of competing interest The authors declared that they have no conflicts of interest to this work., (Copyright © 2023 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background: To summarize the experience of individualized biliary reconstruction techniques in deceased donor liver transplantation and explore potential risk factors for biliary stricture., Methods: We retrospectively collected medical records of 489 patients undergoing deceased donor liver transplantation at our center between January 2016 and August 2020. According to anatomical and pathological conditions of donor and recipient biliary ducts, patients' biliary reconstruction methods were divided into six types. We summarized the experience of six different reconstruction methods and analyzed the biliary complications' rate and risk factors after liver transplantation., Results: Among 489 cases of biliary reconstruction methods during liver transplantation, there were 206 cases of type I, 98 cases of type II, 96 cases of type III, 39 cases of type IV, 34 cases of type V, and 16 cases of type VI. Biliary tract anastomotic complications occurred in 41 cases (8.4%), including 35 cases with biliary stricture (7.2%), 9 cases with biliary leakage (1.8%), 19 cases with biliary stones (3.9%), 1 case with biliary bleeding (0.2%), and 2 cases with biliary infection (0.4%). One of 41 patients died of biliary tract bleeding and one died of biliary infection. Thirty-six patients significantly improved after treatment, and 3 patients received secondary transplantation. Compared with patients without biliary stricture, a higher warm ischemic time was observed in patients with non-anastomotic stricture and more leakage of bile in patients with an anastomotic stricture., Conclusion: The individualized biliary reconstruction methods are safe and feasible to decrease perioperative anastomotic biliary complications. Biliary leakage may contribute to anastomotic biliary stricture and cold ischemia time to non-anastomotic biliary stricture., (© 2023. The Society for Surgery of the Alimentary Tract.)

Background: Anastomotic stricture is a common underlying cause of long-term morbidity after hepaticojejunostomy (HJ) for bile duct injury (BDI) following cholecystectomy. However, there are no methods for predicting stricture risk. This study was aimed at establishing two online calculators for predicting anastomotic stricture occurrence (ASO) and stricture-free survival (SFS) in this patient population., Methods: The clinicopathological characteristics and follow-up information of patients who underwent HJ for BDI after cholecystectomy from a multi-institutional database were reviewed. Univariate and multivariate analyses of the risk factors of ASO and SFS were performed in the training cohort. Two nomogram-based online calculators were developed and validated by internal bootstrapping resamples ( n =1000) and an external cohort., Results: Among 220 screened patients, 41 (18.64%) experienced anastomotic strictures after a median follow-up of 110.7 months. Using multivariate analysis, four variables, including previous repair, sepsis, HJ phase, and bile duct fistula, were identified as independent risk factors associated with both ASO and SFS. Two nomogram models and their corresponding online calculators were subsequently developed. In the training cohort, the novel calculators achieved concordance indices ( C -indices) of 0.841 and 0.763 in predicting ASO and SFS, respectively, much higher than those of the above variables. The predictive accuracy of the resulting models was also good in the internal ( C -indices: 0.867 and 0.821) and external ( C -indices: 0.852 and 0.823) validation cohorts., Conclusions: The two easy-to-use online calculators demonstrated optimal predictive performance for identifying patients at high risk for ASO and with dismal SFS. The estimation of individual risks will help guide decision-making and long-term personalized surveillance., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Bile duct injury (BDI) is one of the serious complications of cholecystectomy procedures, which has a disastrous impact on long-term survival, health-related quality of life (QoL), healthcare costs as well as high rates of litigation. The standard treatment of major BDI is hepaticojejunostomy (HJ). Surgical outcomes depend on many factors, including the severity of the injury, the surgeons' experiences, the patient's condition, and the reconstruction time. The authors aimed to assess the impact of reconstruction time and abdominal sepsis control on the reconstruction success rate., Methods: This is a multicenter, multi-arm, parallel-group, randomized trial that included all consecutive patients treated with HJ for major post-cholecystectomy BDI from February 2014 to January 2022. Patients were randomized according to the time of reconstruction by HJ and abdominal sepsis control into group A (early reconstruction without sepsis control), group B (early reconstruction with sepsis control), and group C (delayed reconstruction). The primary outcome was successful reconstruction rate, while blood loss, HJ diameter, operative time, drainage amount, drain and stent duration, postoperative liver function tests, morbidity and mortality, number of admissions and interventions, hospital stay, total cost, and patient QoL were considered secondary outcomes., Results: Three hundred twenty one patients from three centres were randomized into three groups. Forty-four patients were excluded from the analysis, leaving 277 patients for intention to treat analysis. With univariate analysis, older age, male gender, laparoscopic cholecystectomy, conversion to open cholecystectomy, failure of intraoperative BDI recognition, Strasberg E4 classification, uncontrolled abdominal sepsis, secondary repair, end-to-side anastomosis, diameter of HJ (< 8 mm), non-stented anastomosis, and major complications were risk factors for successful reconstruction. With multivariate analysis, conversion to open cholecystectomy, uncontrolled sepsis, secondary repair, the small diameter of HJ, and non-stented anastomosis were the independent risk factors for the successful reconstruction. Also, group B patients showed decreased admission and intervention rates, decreased hospital stay, decreased total cost, and early improved patient QoL., Conclusion: Early reconstruction after abdominal sepsis control can be done safely at any time with comparable results for delayed reconstruction in addition to decreased total cost and improved patient QoL., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Emergency biliary colic admissions can be managed with an index or elective laparoscopic cholecystectomy (LC). Opting to perform an elective LC may have significant repercussions such as the risk of readmissions before operation with further attacks or with biliary complications (e.g. cholecystitis, pancreatitis, choledocholithiasis). The risk of readmission and biliary complications in patients admitted with biliary colic but scheduled for elective surgery has never been investigated. The secondary aim was to compare rates of peri-operative morbidity between the index admission, elective and readmission LC cohorts., Method: All patients admitted with a diagnosis of biliary colic over a 5-year period and proceeding to LC were included in the study (n = 441). The risk of being readmitted and suffering further morbidity whilst awaiting elective LC was investigated. Peri-operative morbidity was compared between the index admission, elective and readmitted LC groups using univariate and multivariate analysis., Results: Following a biliary colic admission, the risk of readmission whilst awaiting elective LC is significant (2 months-25%; 10 months-48%). In this group, the risks of subsequent biliary complications (18.0%) and the requirement for ERCP (6.5%) were significant. Patients who are readmitted before LC, suffer a more complicated peri-operative course (longer total length of stay, higher post-operative complications, imaging and readmission)., Discussion: Index admission LC for biliary colic avoids the significant risk of readmission and biliary complications before surgery and should be the gold standard. Readmitted patients are likely to have higher rates of peri-operative adverse outcomes. Patients should be counselled about these risks., (© 2022. Crown.)

Background: Bile duct injury (BDI) following cholecystectomy is associated with malpractice litigation. Aim of this study was to evaluate risk factors for litigation in patients with BDI referred in a tertiary care center., Methods: Patients treated for BDI between 1994 and 2016. Stabilized inverse probability therapy weighting was used and multivariable logistic regression analysis identified risk factors for malpractice litigation., Results: Of the 211 treated patients, 98 met the inclusion criteria: early-referral group (<20 days; 51.0%), late-referral (≥20 days; 49.0%). 36 patients (36.7%) initiated malpractice litigation with verdict in favor of plaintiff in 86.7% of cases (median payment = €90 500, up to €600 000). Attempts at surgical and endoscopic repair before referral were significantly higher in late-referral group. Failed postoperative management (delayed referral, attempts at repair before referral) was one of the strongest predictors for litigation. Risk of litigation progressively increased from 23.8%, when referral time was within 19 days, to 54.5% (61-120 days), to 60.0% (121-210 days) and to 65.1% (211-365 days)., Discussion: Litigation rate after BDI was 37%. Delayed referral to tertiary care center was one of the strongest predictors for litigation. Prompt referral to tertiary experienced centers without any attempt at repair may reduce the risk of litigation., Competing Interests: Declaration of competing interest None to declare., (Copyright © 2023 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Introduction: Since the establishment of the Critical view of safety (CVS), different strategies have been created such as bailout procedures (SC, subtotal cholecystectomy), classifications for preoperative and intraoperative complexity (The Parkland grading scale, PGS) and objective evaluation of the CVS (doublet score, DS) to establish a "Culture of Safety in Cholecystectomy, COSIC"; to avoid complications., Methods: A multiple choice questionnaire was applied to residents and graduated surgeons from different Hospitals in Mexico during different national meetings; evaluating the knowledge of this different concepts (CVS, SC, PGS, DS), univariate logistic regression was used to assess the association of the knowledge with adverse events (AE) like the Bile duct injury., Results: A total of 744 questionnaires were evaluated; 284 (38.17%) women and 460 (61.83%) men; 436 (58.6%) were residents and 308 (41.4%) graduated surgeons. 708 (95.16%) reported knowing the CVS; however, only (51.98%, p ≤ 0.001) defined the concept correctly, while 136 (18.28%) reported knowing the DS, but only 44 (5.91%) defined it correctly. Regarding the PGS, 398 (53.49%) mentioned knowing it, but only 262 defined it correctly. The concept of SC 642 (86.29%) reported knowing it; however, only (56.7%, p ≤ 0.001) correctly defined the techniques, being the reconstituting technique the preferred one (42.37% vs 34.89%). In this survey, the correct knowledge of the CVS (OR 0.47, p < 0.001), the subtotal techniques (OR 0.71 p = 0.07), the DS (OR 0.48 p < 0.001) and of the PGS (OR 0.28, p < 0.001) decreased the risk of presenting BDI., Conclusion: Despite the COSIC and the timing of publication of the CVS; the percentage of people who can correctly define basic safety concepts is low among residents and licensed surgeons. Therefore, it is important to emphasize the dissemination of these concepts to obtain safe LC and thus reduce the incidence of complications., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Laparoscopic cholecystectomy with fluorescent cholangiography using indocyanine green dye (FC) identifies extrahepatic biliary structures, potentially augmenting the critical view of safety. We aim to describe trends for the largest single-center cohort of patients undergoing FC in laparoscopic cholecystectomy., Study Design: A retrospective review of a prospectively maintained database identified patients undergoing laparoscopic cholecystectomy with FC at a single academic institution. Patient factors included age, sex, BMI, and American Society of Anesthesiologists score. Outcomes included operative time, conversion to open procedure, biliary injury, length of stay, and complications., Results: A total of 828 patients underwent FC. Of these, 74.3% were female, the mean age was 50.4 years, and the average BMI 28.8 kg/m 2 . Mean operating room time was 68.6 minutes. There were no mortalities or common bile duct injuries. Morbidities included 4 bile leaks and 1 retained stone. Six patients required conversion to an open approach. Operative time, length of stay, and open conversion significantly decreased after a standard indocyanine green protocol (p &lt; 0.05). Compared with white light, FC demonstrated lower operative times (99 vs 68 minutes), length of stay (1.4 vs 0.4 days), open conversions (8% vs 0.7%), emergency department visits (13% vs 8%) and drain placements (12% vs 3%) (all p &lt; 0.05). Patients with BMI greater than 30 saw elevated operative times and length of stay., Conclusions: In conclusion, this paper demonstrates improved operative outcomes with the use of FC through the consistent ability to delineate biliary anatomy, even in the setting of complex anatomy. No common bile duct injuries have occurred in our 7-year experience with FC. We recommend FC as the standard of care when performing laparoscopic cholecystectomies., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

The aim of the study is to report the outcomes of reoperative surgery for late failure of postcholecystectomy bile duct injury (BDI) repair. All the patients, who underwent a reoperative surgery for late failure of postcholecystectomy BDI repair at our institution between August 2007 and July 2020, were retrospectively reviewed. Of the total 262 patients of BDI repair, 66 underwent reoperative surgery for late failure. Median duration between last attempt repair and the onset of recurrent symptoms was 18 months. Eighty-five percent of patients with failed repair became symptomatic within 5 years of attempt repair. The most common type of BDI was E3. All the patients underwent Roux-en-Y hepaticojejunostomy. Twenty-nine postoperative complications developed in 23 (35%) patients. Postoperative mortality was 1.5%. Median postoperative hospital stay was 9 (5-61) days. Over a median follow-up of 80 (12-150) months, 5.2% (3/58) of patients developed clinically relevant anastomotic stricture. Three patients with secondary biliary cirrhosis died in the follow-up period due to decompensated liver disease. Overall, excellent or good long-term outcome was achieved in 83% (48/58) of patients which was significantly less satisfactory than primary repair patients (82.8% vs 92.7%, p = 0.039). Reoperative surgery is safe in patients with failed repair after postcholecystectomy BDI and good long-term clinical success can be achieved in most of the patients. The long-term results were less satisfactory in failed-repair group than those who underwent primary repair at our institution. Early referral to a specialized unit for BDI repair may improve long-term outcome., (© 2022. Italian Society of Surgery (SIC).)

Iatrogenic bile duct injury still represents a serious complication mostly connected with minimally invasive cholecystectomy. This complication has an important impact both on short- and long-term morbidity and is associated with non-negligible mortality. The objective of our study was to provide a comprehensive summary of information based on the most recent guidelines with recommendations for how to prevent a bile duct injury, how to reach an early diagnosis and finally, how to proceed should they occur in order to minimize further damage. We also present ATOM, a new classification of bile duct injuries that provides clear information not only about the extent of anatomical damage, but also about the time and mechanism of its occurrence.

Background: Cholecystectomies can sometimes be very complex operations, which place high demands on the surgeon., Objective: Are there preoperative and intraoperative procedures available for reducing the risk of intraoperative bile duct injuries during a complex cholecystectomy?, Results: The complexity of the operation should be estimated preoperatively. Extended diagnostic examinations, preoperative biliary stenting and the performance of the operation by an experienced surgeon may help to reduce the operative risk. In high-risk patients, postponing the cholecystectomy may be indicated. The timely intraoperative recognition of the impossibility to perform a regular cholecystectomy is of decisive importance. In this situation, so-called bail-out procedures, such as fundus-down cholecystectomy or subtotal cholecystectomy are warranted. Conversion from laparoscopic to open surgery is not always necessary., Conclusion: Bail-out procedures are useful to reduce the risk of bile duct injuries during complex cholecystectomy and can enable a safe completion of the operation., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Cholecystectomy is considered a general surgical operation. However, general surgeons are not trained to manage severe complications such as bile duct injury (BDI) and should refer to hepatopancreatobiliary (HPB) surgeons when difficulty arises. This study aimed to investigate the outcomes of patients who had on-table HPB consults during cholecystectomy., Methods: This is an audit of 50 patients who required on-table HPB consult during cholecystectomy from 2011 to 2017. Consultations were classified as "proactive" and "reactive", where consults were made before or after surgical incision, respectively. Patient demographics and perioperative details were collected., Results: The median age of the patients was 62.5 years [interquartile range (IQR) 50.8-71.3 years]. Eight (16%) patients had underlying HPB co-morbidity. Gallbladder wall was thickened in all patients (median 5 mm, IQR 4-7 mm), and common bile duct was of normal caliber in all patients (median 5 mm, IQR 4-6 mm). Median length of operation and length of stay were 165 min (IQR 124-209 min) and five days (IQR 3-7 days), respectively. Subtotal cholecystectomy was performed in 18 (36%) patients. Forty-eight patients were initially managed by laparoscopic approach, 15 (31%) required open conversion; majority (9/15, 60%) were initiated before on-table consult. Majority of referrals (98%) were reactive. Common reasons for referral included unclear anatomy or anatomical variations (30%), presence of dense adhesions and/or contracted gallbladder (18%) and impacted stones in Hartmann's pouch (16%). Three (6%) patients were referred for BDI (2 Strasberg D and 1 Strasberg E1), and two (4%) were referred for torrential bleeding from arterial injury (1 cystic artery and 1 right hepatic artery). Any morbidity and 30-day readmission were 22% and 6%, respectively. There was no 90-day mortality., Conclusions: Calling for help in BDI is obligatory, but in other instances is a personal choice. Calling for help prior to open conversion is lacking and this awareness should be raised. Whether surgical outcomes could be improved by early HPB consult needs to be determined by larger multicenter reports., (Copyright © 2022. Published by Elsevier B.V.)

Objective: To analyze the perioperative and long-term outcomes of patients undergoing LT due to BDI in a tertiary care center., Background: BDI is associated with significant morbidity and long-term impact on quality of life. LT represents the only possibility of a cure in patients with BDI who develop SBC., Methods: Retrospective cohort study from a prospective LT database. Between 2008 and 2019, patients with SBC due to BDI after cholecystectomy and requiring LT were identified. Perioperative and long-term outcomes were analyzed., Results: Among 354 LT, 12 patients underwent LT to treat post-cholecystectomy BDI and accounted for 3.4% of all LT. The median time from BDI to SBC diagnosis was 9.3 years (2.4-14). The mean time from SBC to inclusion on the waitlist was 2.4years (± 2.2). Postoperative complications occurred in 11 patients (91.6%); mainly infectious (9/12 patients, 75%), followed by renal complications (4/12 patients, 33.3%). Only 2 patients developed major complications, which were the patients who died, resulting in a 90-day mortality of 16.7%. After a mean follow-up of 40.3 months (± 42.2) survival at 1, 3, and 5 years was 83%., Conclusions: Although BDI is an unusual indication for LT worldwide, it accounted for 3.4% of all LT in our center. Although postoperative mortality remains high, LT is the only possibility of a cure, with acceptable long-term outcomes. Early referral to a tertiary care center is essential to avoid long-term complications of BDI, such as SBC., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Bile duct injury (BDI) is one of the serious complications in laparoscopic cholecystectomy (LC), but there is currently a lack of systematic review of risk factors related to BDI after LC. This study conducts meta-analysis on the risk factors related to bile duct injury after LC, the purpose is to provide reference basis for preventing and reducing BDI after LC., Methods: Using the Computer to retrieve of Chinese and English databases such as CNKI, WANFANG Data, the VIP Network, PubMed, Embase, the Cochrane Library, etc. The time is from the establishment of each database until August 2021. A case-control study is selected that is related to the risk factors of BDI after LC. This meta-analysis using RevMan 5.4 and State 12.0 software is performed after two researchers independently sift through the literature, extract the data, and evaluate the bias risk included in the study., Results: The risk factors related to BDI after LC will be analyzed by systematic review., Conclusion: The conclusion of this study will play an important role in reducing BDI after LC., Osf Registration: DOI 10.17605/OSF.IO/2B3K9, the registration URL is https://osf.io/2b3k9., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Donation after circulatory death (DCD) has expanded the donor pool for liver transplantation. However, ischemic cholangiopathy (IC) after DCD liver transplantation causes inferior outcomes. The molecular mechanisms of IC are currently unknown but may depend on ischemia-induced genetic reprograming of the biliary epithelium to mesenchymal-like cells. The main objective of this study was to determine if cholangiocytes undergo epithelial to mesenchymal transition (EMT) after exposure to DCD conditions and if this causally contributes to the phenotype of IC. Human cholangiocyte cultures were exposed to periods of warm and cold ischemia to mimic DCD liver donation. EMT was tested by assays of cell migration, cell morphology, and differential gene expression. Transplantation of syngeneic rat livers recovered under DCD conditions were evaluated for EMT changes by immunohistochemistry. Human cholangiocytes exposed to DCD conditions displayed migratory behavior and gene expression patterns consistent with EMT. E-cadherin and CK-7 expressions fell while N-cadherin, vimentin, TGFβ, and SNAIL rose, starting 24 hours and peaking 1-3 weeks after exposure. Cholangiocyte morphology changed from cuboidal (epithelial) before to spindle shaped (mesenchymal) a week after ischemia. These changes were blocked by pretreating cells with the Transforming Growth Factor beta (TGFβ) receptor antagonist Galunisertib (1 μM). Finally, rats with liver isografts cold stored for 20 hours in UW solution and exposed to warm ischemia (30 minutes) at recovery had elevated plasma bilirubin 1 week after transplantation and the liver tissue showed immunohistochemical evidence of early cholangiocyte EMT. Our findings show EMT occurs after exposure of human cholangiocytes to DCD conditions, which may be initiated by upstream signaling from autocrine derived TGFβ to cause mesenchymal specific morphological and migratory changes., Competing Interests: The authors have declared that no competing interests exist.

Background: To present abdominal multi-slice computed tomography (MSCT) results following transplantation in pediatric patients with a liver transplantation (LT), and to create awareness of early (<3 months) and late (>3 months) complications that may occur., Methods: This retrospective study included 119 children with an LT performed in our hospital from 2014 to 2017. The descriptive statistics relating to patients' age, gender, transplantation indications, transplantation technique, and MSCT findings were calculated, and are presented as numbers and percentages. The complications were divided into 4 groups: vascular, biliary, parenchymal, and extraparenchymal., Results: The LT procedures were performed with organs from living donors for 83 patients, and from deceased donors for 36 patients. Hepatic artery and portal vein complications were mostly seen in the early period (n = 18), and hepatic vein complications were also observed in the late period (n = 6). The most commonly encountered biliary complications were stenosis/stricture (n = 13) and bile leak/ bilioma (n = 9). Stenosis/stricture frequently occurred in the late period. The most common parenchymal complications were ischemic infarct (n = 8) in the early period, and abscess (n = 4) and recurrent hepatoblastoma (n = 2) in the late period. Hematoma (n = 7), intestinal perforation (n = 3), and focal spleen infarct (n = 3) were among the most commonly observed extraparenchymal abdominal complications., Conclusion: The complications occurring after pediatric LT varied according to the time after surgery and the transplantation technique used. Using MSCT, different abdominal complications can be assessed simultaneously, greatly contributing to diagnosis and treatment.

Background: Bile duct injury and conversion-to-open-surgery rates remain unacceptably high during laparoscopic and robotic cholecystectomy. In a recently published randomized clinical trial, using near-infrared fluorescent cholangiography with indocyanine green intraoperatively markedly enhanced biliary-structure visualization. Our systematic literature review compares bile duct injury and conversion-to-open-surgery rates in patients undergoing laparoscopic or robotic cholecystectomy with versus without near-infrared fluorescent cholangiography., Methods: A thorough PubMed search was conducted to identify randomized clinical trials and nonrandomized clinical trials with ≥100 patients. Because all near-infrared fluorescent cholangiography studies were published since 2013, only studies without near-infrared fluorescent cholangiography published since 2013 were included for comparison. Incidence estimates, weighted and unweighted for study size, were adjusted for acute versus chronic cholecystitis, and for robotic versus laparoscopic cholecystectomy and are reported as events/10,000 patients. All studies were assessed for bias risk and high-risk studies excluded., Results: In total, 4,990 abstracts were reviewed, identifying 5 near-infrared fluorescent cholangiography studies (3 laparoscopic cholecystectomy/2 robotic cholecystectomy; n = 1,603) and 11 not near-infrared fluorescent cholangiography studies (5 laparoscopic cholecystectomy/4 robotic cholecystectomy/2 both; n = 5,070) for analysis. Overall weighted rates for bile duct injury and conversion were 6 and 16/10,000 in near-infrared fluorescent cholangiography patients versus 25 and 271/10,000 in patients without near-infrared fluorescent cholangiography. Among patients undergoing laparoscopic cholecystectomy, bile duct injuries, and conversion rates among near-infrared fluorescent cholangiography versus patients without near-infrared fluorescent cholangiography were 0 and 23/10,000 versus 32 and 255/10,000, respectively. Bile duct injury rates were low with robotic cholecystectomy with and without near-infrared fluorescent cholangiography (12 and 8/10,000), but there was a marked reduction in conversions with near-infrared fluorescent cholangiography (12 vs 322/10,000)., Conclusion: Although large comparative trials remain necessary, preliminary analysis suggests that using near-infrared fluorescent cholangiography with indocyanine green intraoperatively sizably decreases bile duct injury and conversion-to-open-surgery rates relative to cholecystectomy under white light alone., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The c-Jun N-terminal kinase (JNK) signaling pathway mediates adaptation to stress signals and has been associated with cell death, cell proliferation, and malignant transformation in the liver. However, up to now, its function was experimentally studied mainly in young mice. By generating mice with combined conditional ablation of Jnk1 and Jnk2 in liver parenchymal cells (LPCs) (JNK1/2 LPC-KO mice; KO, knockout), we unraveled a function of the JNK pathway in the regulation of liver homeostasis during aging. Aging JNK1/2 LPC-KO mice spontaneously developed large biliary cysts that originated from the biliary cell compartment. Mechanistically, we could show that cyst formation in livers of JNK1/2 LPC-KO mice was dependent on receptor-interacting protein kinase 1 (RIPK1), a known regulator of cell survival, apoptosis, and necroptosis. In line with this, we showed that RIPK1 was overexpressed in the human cyst epithelium of a subset of patients with polycystic liver disease. Collectively, these data reveal a functional interaction between JNK signaling and RIPK1 in age-related progressive cyst development. Thus, they provide a functional linkage between stress adaptation and programmed cell death (PCD) in the maintenance of liver homeostasis during aging., Competing Interests: The authors declare no competing interest., (Copyright © 2021 the Author(s). Published by PNAS.)

Background: Bile duct injury (BDI) is a severe complication following cholecystectomy. Early recognition and treatment of BDI has been shown to reduce costs and improve patients' quality of life. The aim of this study was to assess the effect and cost-effectiveness of routine versus selective intraoperative cholangiography (IOC) in cholecystectomy., Methods: A systematic review and meta-analysis, combined with a health economic model analysis in the Swedish setting, was performed. Costs per quality-adjusted life-year (QALY) for routine versus selective IOC during cholecystectomy for different scenarios were calculated., Results: In this meta-analysis, eight studies with more than 2 million patients subjected to cholecystectomy and 9000 BDIs were included. The rate of BDI was estimated to 0.36 per cent when IOC was performed routinely, compared with to 0.53 per cent when used selectively, indicating an increased risk for BDI of 43 per cent when IOC was used selectively (odds ratio 1.43, 95 per cent c.i. 1.22 to 1.67). The model analysis estimated that seven injuries were avoided annually by routine IOC in Sweden, a population of 10 million. Over a 10-year period, 33 QALYs would be gained at an approximate net cost of €808 000 , at a cost per QALY of about €24 900., Conclusion: Routine IOC during cholecystectomy reduces the risk of BDI compared with the selective strategy and is a potentially cost-effective intervention., (© The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd.)

Background: This study aimed to identify a subgroup of recipients at low risk of haemorrhage, bile leakage and ascites following liver transplantation (LT)., Methods: Factors associated with significant postoperative ascites (more than 10 ml/kg on postoperative day 5), bile leakage and haemorrhage after LT were identified using three separate multivariable analyses in patients who had LT in 2010-2019. A model predicting the absence of all three outcomes was created and validated internally using bootstrap procedure., Results: Overall, 944 recipients underwent LT. Rates of ascites, bile leakage and haemorrhage were 34.9, 7.7 and 6.0 per cent respectively. The 90-day mortality rate was 7.0 per cent. Partial liver graft (relative risk (RR) 1.31; P = 0.021), intraoperative ascites (more than 10 ml/kg suctioned after laparotomy) (RR 2.05; P = 0.001), malnutrition (RR 1.27; P = 0.006), portal vein thrombosis (RR 1.56; P = 0.024) and intraoperative blood loss greater than 1000 ml (RR 1.39; P = 0.003) were independently associated with postoperative ascites and/or bile leak and/or haemorrhage, and were introduced in the model. The model was well calibrated and predicted the absence of all three outcomes with an area under the curve of 0.76 (P = 0.001). Of the 944 patients, 218 (23.1 per cent) fulfilled the five criteria of the model, and 9.6 per cent experienced postoperative ascites (RR 0.22; P = 0.001), 1.8 per cent haemorrhage (RR 0.21; P = 0.033), 4.1 per cent bile leak (RR 0.54; P = 0.048), 40.4 per cent severe complications (RR 0.70; P = 0.001) and 1.4 per cent 90-day mortality (RR 0.13; P = 0.004)., Conclusion: A practical model has been provided to identify patients at low risk of ascites, bile leakage and haemorrhage after LT; these patients could potentially qualify for inclusion in non-abdominal drainage protocols., (© The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd.)

Background: Bile duct injury and vasculobiliary injury are possible complications during laparoscopic cholecystectomy which can lead to increased morbidity, mortality, costs of hospitalization and litigation. Proper documentation of the critical view of safety and safe plane of dissection may play a crucial role for archivization, teaching and medicolegal purposes., Methods: The study group consisted of 100 patients with symptomatic cholecystolithiasis qualified for laparoscopic cholecystectomy. The critical view of safety was documented on two photographs and safe plain of dissection obtained with laparoscopic ultrasound was documented on one photograph as well as the whole procedure was recorded. The photographs were printed in the operating theatre and videos were stored on an external hard drive., Results: The mean time to obtain and analyse photographs was significantly shorter than video, and the size of the stored data was significantly smaller for photographs than videos. The cost of one documentation procedure was significantly lower for video than photographs. Critical view of safety was obtained in 91 patients, and laparoscopic ultrasound was successful in 99 patients. The conversion rate was 2%, and fundus-first cholecystectomies were performed in 6% of patients. We did not observe any biliary and vascular complications., Conclusions: Photographic documentation of the critical view of safety and safe plane of dissection should be an inherent part of laparoscopic cholecystectomy. Our proposal of documentation prepared in the operating theatre and stored in the patient's documentation is an example of an easy, fast and cheap method of data archivization.

Background and Aims: Minimally invasive treatments of anastomotic benign biliary stricture (BBS) after orthotopic liver transplantation (OLT) include endoscopic placement of multiple plastic stents or fully covered self-expandable metal stents (FCSEMSs). No multiyear efficacy data are available on FCSEMS treatment after OLT., Methods: We prospectively studied long-term efficacy and safety of FCSEMS treatment in adults aged ≥18 years with past OLT, cholangiographically confirmed BBS, and an indication for ERCP with stent placement. Stent removal was planned after 4 to 6 months, with subsequent follow-up until 5 years or stricture recurrence. Long-term outcomes were freedom from stricture recurrence, freedom from recurrent stent placement, and stent-related serious adverse events (SAEs)., Results: In 41 patients, long-term follow-up began after FCSEMS removal (n = 33) or observation of complete distal migration (CDM) (n = 8). On an intention-to-treat basis, the 5-year probability of remaining stent-free after FCSEMS removal or observation of CDM was 48.9% (95% confidence interval [CI], 33.2%-64.7%) among all patients and 60.9% (95% CI, 43.6%-78.2%) among 31 patients with over 4 months of FCSEMS indwell time. In 28 patients with stricture resolution at FCSEMS removal or observed CDM (median, 5.0 months indwell time), the 5-year probability of no stricture recurrence was 72.6% (95% CI, 55.3%-90%). Sixteen patients (39%) had at least 1 related SAE, most commonly cholangitis (n = 10)., Conclusions: By 5 years after temporary FCSEMS treatment of post-OLT BBS, approximately half of all patients remained stent-free on an intention-to-treat basis. Stent-related SAEs (especially cholangitis) were common. FCSEMS placement is a viable long-term treatment option for patients with post-OLT BBS. (Clinical trial registration number: NCT01014390.)., (Copyright © 2020 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Biliary complications post liver transplantation are a significant source of morbidity and mortality and early recognition is paramount to the long-term success of the liver graft. Part II of this series will focus on liver transplant biliary anatomy, including the blood supply to the biliary system and potential problems if it is interrupted. The imaging rationale for investigating suspected biliary complications, potential pitfalls, and treatment options will be discussed. The various biliary complications will be illustrated using a collection of cases., (Copyright © 2020 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

We present the case of a 28-year-old man with recently-diagnosed human immunodeficiency virus and hepatitis C virus infection. He developed obstructive cholangiopathy secondary to cytomegalovirus and Kaposi sarcoma, both diagnosed by endoscopic retrograde cholangiopancreatography and biopsies. He received antiretroviral therapy, chemotherapy and valganciclovir with full recovery.

Background: We sought to determine the prevalence of common anatomic landmarks around the gallbladder that may be useful in orienting surgeons during laparoscopic cholecystectomy., Methods: The subhepatic anatomy of 128 patients undergoing elective cholecystectomy was recorded. We searched and recorded the presence of five anatomic landmarks: the bile duct (B), the Sulcus of Rouviere (S), the left hepatic artery (A), the umbilical fissure (F), and the duodenum (E). These are the previously described B-SAFE landmarks., Results: We found that the duodenum and umbilical fissure were present reliably in almost all patients. The position of the left hepatic artery could be reliably determined by its pulsation in 84% of patients. A portion of the bile duct could be seen in 77% and the Sulcus of Rouviere was present in 80%. Furthermore, the hepatobiliary triangle was always found superior or at the same level as the Sulcus of Rouviere., Conclusions: We found that these five anatomic landmarks were reliably present. This suggest that using the B-SAFE landmarks may allow a surgeon to more easily orient before and during laparoscopic cholecystectomy and prevent bile duct injuries.

Introduction: The timing of cholecystectomy for acute cholecystitis has been debated with most studies favoring early cholecystectomy (< 72 h of onset). However, most reported studies are from single institution studies with only a few population-based studies. The purpose of this study is to compare clinical outcomes of patients undergoing cholecystectomy within 72 h of emergency department (ED) presentation to patients undergoing cholecystectomy following 72 h in a large statewide database., Methods: The New York SPARCS administrative database was used to identify all adult patients presenting to the ED with a diagnosis of acute cholecystitis from 2005 to 2016. Patients aged < 18, missing data, or other biliary diagnoses were excluded from the analysis. Early cholecystectomy was defined as within 72 h of presentation to the emergency department. Early vs late groups were compared in terms of overall complications, bile duct injury (BDI), hospital length of stay (LOS), 30-days ED visits and readmissions. The linear trends of yearly early/late cholecystectomies were examined using a log-linear Poisson regression models. Multivariable logistic regression model was used to compare complications, BDI, and 30-day readmission/ED visits after controlling for confounding factors. Multivariable generalized linear regression for a negative binomial distributed count data was used to compare LOS., Results: Following the application of the inclusion/exclusion criteria, there were 109,862 patients who presented to an ED with the diagnosis of acute cholecystitis. The majority of patients underwent early cholecystectomy (n = 93,761, 85.3%), whereas only 16,101 patients underwent late cholecystectomy (14.7%). There was an increasing trend of early cholecystectomy from 2005 (81.1%) to 2016 (87.8%). On multivariable regression, patients with early cholecystectomy were less likely to have complications (OR 0.542, 95% CI 0.518-0.566), had shorter LOS (ratio 0.461, 95% CI 0.458-0.465), were less likely to have 30-day readmission (OR 0.871, 95% CI 0.816-0.928), 30-day ED visits (OR 0.909, 95% CI 0.862-0.959), and bile duct injury (OR 0.654, 95% CI 0.444-0.962) compared to late cholecystectomy patients., Conclusion: Early cholecystectomy (< 72 h) is associated with fewer complications, specifically BDI, shorter LOS, and fewer 30-day readmissions and ED visits. For patients presenting to the ED for acute cholecystitis, early cholecystectomy should be preferred.

Background: Enhanced Recovery After Surgery (ERAS) for patients undergoing pancreatoduodenectomy is associated with reduced length of stay (LOS) and morbidity. However, external validating of the impact is difficult due to the multimodal aspects of ERAS. This study aimed to assess implementation of ERAS for pancreatoduodenectomy with a composite measure of multiple ideal outcome indicators defined as 'textbook outcome' (TBO)., Methods: In a tertiary referral center, 250 patients undergoing pancreatoduodenectomy were included in ERAS (May 2012-January 2017) and compared to a cohort of 125 patients undergoing traditional perioperative management (November 2009-April 2012). TBO was defined as proportion of patients without prolonged LOS, Clavien-Dindo ≥ III complications, postoperative pancreatic fistula, postpancreatectomy hemorrhage, bile leakage, readmissions or 30-day/in-hospital mortality. Additionally, overall treatment costs were calculated and compared using bootstrap independent t-test., Results: The two cohorts were comparable in terms of demographic and surgical details. Implementation of ERAS was associated with reduced median LOS (10 days vs 13 days, p < 0.001) and comparable overall complication rate (62.0% vs 61.6%, p = 0.940) when compared to the traditional management group. In addition, a higher proportion of patients achieved TBO (56.4% vs 44.0%, p = 0.023) when treated according to ERAS principles. Furthermore, ERAS was associated with reduced mean total costs (£18132 vs £19385, p < 0.005)., Conclusion: Implementation of ERAS for patients undergoing pancreatoduodenectomy is beneficial for both patients and hospitals. ERAS increased the proportion of patients achieving TBO and reduced overall costs. TBO is a potential measure for the evaluation of ERAS., Competing Interests: Declaration of competing interest None., (Crown Copyright © 2020. Published by Elsevier B.V. All rights reserved.)

Background: In recent years there has been a growing interest in the application of minimally invasive surgery in the management of cholecystectomy-related injury to the biliary tract. The aim of this analysis was to identify and combine the available evidence on the argument, with particular reference to major injuries to the main bile duct requiring biliodigestive anastomosis., Methods: The PubMed/MEDLINE, Embase, and Web of Science electronic databases were queried through May 2019. Inclusion criteria considered all studies reporting detailed data about patients with bile duct injury following cholecystectomy receiving minimally invasive (both laparoscopic and robotic) surgical repair. Clinical outcomes data were pooled and analyzed., Results: A total of 31 studies reporting on the outcomes of 218 patients were eventually included in the analysis, whereby 148 patients with type D or E injury. Of these, there were 31 patients (21%) receiving direct bile duct repair and 117 patients (79%) undergoing bilioenteric reconstruction. Among patients with major bile duct injury, postoperative morbidity was 24%, being 12% the incidence of major complications and 6% the rate of patients requiring subsequent, further surgery., Conclusions: The absence of high-level evidences precludes the possibility to draw definitive conclusions. However, the available data derived from a growing number of centers demonstrate that minimally invasive surgery may offer its well-known advantages on postoperative outcomes also in the setting of severe iatrogenic injury to the bile ducts., (© 2020 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Background and Aims: Temporary single, fully covered self-expanding metal stent (FCSEMS) placement for benign biliary strictures (BBSs) associated with chronic pancreatitis (CP) may require fewer interventions than endotherapy with multiple plastic stents and may carry less morbidity than biliary diversion surgery. This study aimed to assess long-term outcomes in CP-associated BBSs after FCSEMS placement and removal., Methods: In this open-label, multinational, prospective study, subjects with CP and a BBS treated with FCSEMS placement with scheduled removal at 10 to 12 months were followed for 5 years after FCSEMS indwell. Kaplan-Meier analyses assessed BBS resolution and cumulative probability of freedom from recurrent stent placement to 5 years after FCSEMS indwell., Results: One hundred eighteen patients were eligible for FCSEMS removal. At a median of 58 months (interquartile range, 44-64) post-FCSEMS indwell, the probability of remaining stent-free was 61.6% (95% confidence interval [CI], 52.5%-70.7%). In 94 patients whose BBSs resolved at the end of FCSEMS indwell, the probability of remaining stent-free 5 years later was 77.4% (95% CI, 68.4%-86.4%). Serious stent-related adverse events occurred in 27 of 118 patients (22.9%); all resolved with medical therapy or repeated endoscopy. Multivariate analysis identified severe CP (hazard ratio, 2.4; 95% CI, 1.0-5.6; P = .046) and longer stricture length (hazard ratio, 1.2; 95% CI, 1.0-1.4; P = .022) as predictors of stricture recurrence., Conclusion: In patients with symptomatic BBSs secondary to CP, 5 years after placement of a single FCSEMS intended for 10 to 12 months indwell, more than 60% remained asymptomatic and stent-free with an acceptable safety profile. Temporary placement of a single FCSEMS may be considered as first-line treatment for patients with CP and BBSs. (Clinical trial registration number: NCT01014390.)., (Copyright © 2020. Published by Elsevier Inc.)

Purpose: To determine how frequently and how severely intra-abdominal structures are affected by transabdominal thoracic duct embolization (TDE)., Materials and Methods: Thirty-five TDE procedures in 35 patients (22 male; mean age, 57 y; age range, 10-79 y) with therapy-refractory chylous effusions were evaluated in which radiopaque embolization material outlined the access route on postinterventional CT. CT data were analyzed by 2 TDE-experienced radiologists. Abdominal structures and organs transgressed by the access route were recorded, and findings were correlated with clinical postinterventional course with follow-up of at least 44 days., Results: Intra-abdominal structures/organs transgressed most often by the access route were the liver (n = 28), crus of the diaphragm (n = 25), pancreas (n = 14), portal vein (n = 10), duodenum (n = 7), inferior vena cava (n = 5), colon (n = 3), left renal vein (n = 2), pleura (n = 2), pericardium (n = 2), and gastric sleeve (n = 2). Pancreatitis was observed in 1 of 14 patients after pancreatic transgression. One case of clinically occult pulmonary glue migration occurred on catheter pullback through the left renal vein. Biliary peritonitis was observed after gallbladder puncture, necessitating cholecystectomy in 1 of 2 transbiliary punctures. No other relevant procedure-related complications such as hemorrhages or infectious complications were observed., Conclusions: Despite transgression of intra-abdominal structures, puncture- and access-related complications of TDE are rare. Transpancreatic manipulations are reasonably well tolerated., (Copyright © 2019 SIR. Published by Elsevier Inc. All rights reserved.)

Objectives: Our aim was to evaluate the influence of the localization of right posterior bile duct anatomy relative to portal vein of the donors on posttransplant bile duct complications., Materials and Methods: We retrospectively investigated 141 patients who had undergone living donor liver transplant using right hemiliver grafts. The patients were classified based on the pattern of the right posterior bile duct and divided into infraportal and supraportal types. Clinical donor and recipient risk factors and surgical outcomes were compared for their relationship with biliary complications using logistic regression analyses., Results: The 2 groups were similar according to demographic and clinical features. The biliary complication rate was 23.7% (9/38) in the infraportal group and 47.4% (37/78) in the supraportal group (P = .014). An analysis of risk factors for the development of anastomotic bile leak using logistic regression showed that a supraportal right posterior bile duct anatomy was a statistically significant positive predictor, with odds ratio of 18.905 (P = .012; confidence interval, 1.922-185.967). The distance of the right posterior bile duct from confluence was significantly lower in patients with biliary complications than in those without (mean of 7.66 vs 0.40 mm; P = .044). According to receiver operating characteristic analyses, the cut-off point for the length of right bile duct to right posterior bile duct from the hepatic confluence was 9.5 mm regarding presence of complications., Conclusions: Factors influencing bile duct anastomosis leakage were supraportal-type donor bile duct anatomy and length of the right main bile duct from biliary confluence. Hepatic arterial complications were similarly a risk factor for biliary strictures. Because of the multiple factors leading to complications in living donor liver transplant, it is challenging to group these patients by operative risk; however, establishing risk models may facilitate the prediction of complications.

Background: Iatrogenic bile duct injuries (BDIs) are mostly associated with laparoscopic cholecystectomy but may also occur following gastroduodenal surgery or liver resection. Delayed diagnosis of type of injury with an ongoing biliary leak as well as the management in a non-specialized general surgical units are still the main factors affecting the outcome., Case Presentation: Herein we present three types of BDIs (Bismuth type I, IV and V) following three different types of upper abdominal surgery, ie. Billroth II gastric resection, laparoscopic cholecystectomy and left hepatectomy. All of them were complex injuries with complete bile duct transections necessitating surgical treatment. All were also very difficult to treat mainly because of a delayed diagnosis of type of injury, associated biliary leak and as a consequence severe inflammatory changes within the liver hilum. The treatment was carried out in our specialist hepatobiliary unit and first focused on infection and inflammation control with adequate biliary drainage. This was followed by a delayed surgical repair with the technique which had to be tailored to the type of injury in each case., Conclusion: We emphasize that staged and individualized treatment strategy is often necessary in case of a delayed diagnosis of complex BDIs presenting with a biliary leak, inflammatory intraabdominal changes and infection. Referral of such patients to expert hepatobiliary centres is crucial for the outcome.

Background: Complications and litigation after bile duct injury (BDI) result in clinical and economic burden. The aim of this study was to comprehensively evaluate the long-term clinical and economic impact of major BDI., Method: Patients with long-term follow-up after Strasberg E BDI were identified. Costs of treatment and litigation were the primary outcome. Relationships between these outcomes and repair factors, like timing of repair and surgeon expertise, were secondary outcomes., Results: Among 139 patients with a median follow up of 10.7 years, 40% of patients developed biliary complications. Repairs by non-specialist surgeons had significantly higher follow up and treatment costs than those by specialists (£25,814 vs. £14,269, p < 0.001). Estimated litigation costs were higher in delayed than immediate repairs (£23,295 vs. £12,864). As such, the lowest average costs per BDI are after immediate specialist repair and the highest after delayed non-specialist repair (£27,133 vs. £49,109, ×1.81 more costly, p < 0.001). Repair by a non-specialist surgeon (HR: 4.00, p < 0.001) and vascular injury (HR: 2.35, p = 0.013) were significant independent predictors of increased complication rates., Conclusion: Costs of major BDI are considerable. They can be reduced by immediate on-table repair by specialist surgeons. This must therefore be considered the standard of care wherever possible., (Copyright © 2019 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Bile duct injuries after cholecystectomy remain a major concern because their incidence has not changed through the years despite technical advances. This video presents a robotic left hepatectomy and Roux-en-Y hepaticojejunostomy as a treatment for a complex bile duct injury after laparoscopic cholecystectomy., Methods: A 52-year-old man underwent laparoscopic cholecystectomy at another institution 8 years previously, which resulted in a bile duct injury. His postoperative period was complicated by jaundice and cholangitis. He was treated with endoscopic retrograde cholangiopancreatography and multiple endoprostheses for 3 years, after which the endoprostheses were removed, and he was sent to the authors' institution. Computed tomography showed that the left liver had signs of disturbed perfusion and dilation of the left intrahepatic bile duct. The patient was asymptomatic and refused any further attempt at surgical correction of the lesion. He was accompanied for 5 years. Magnetic resonance imaging showed progressive atrophy of the left liver. Finally, 3 months before this writing, he presented with intermittent episodes of cholangitis. A multidisciplinary team decided to perform left hepatectomy with Roux-en-Y hepatojejunostomy via a robotic approach. The left liver was atrophied, and left hepatectomy was performed. Fluorescence imaging was used to identify the right bile duct. At opening of the right bile duct, small stones were found and removed. Antecolic Roux-en-Y hepaticojejunostomy then was performed., Results: The operative time was 335 min. Recovery was uneventful, and the patient was discharged on postoperative day 4., Conclusions: Robotic repair of bile duct injuries is feasible and safe, even when liver resection is necessary. This video may help oncologic surgeons to perform this complex procedure.

Background: This study was designed to analyze the feasibility of extra-anatomical hepatic artery (HA) reconstruction in living donor liver transplantation (LT)., Methods: Patients who underwent their first living donor LT at our center between January 2008 and December 2017 were reviewed. HA reconstruction was classified as anatomical or extra-anatomical reconstruction (EAR). We compared the background characteristics and posttransplantation outcomes, including complications, biliary complications, graft survival, and overall survival. The potential risk factors for bile leakage were analyzed using multivariable logistic regression, while risk factors for biliary stricture-free survival, graft survival, and overall survival were analyzed using multivariable Cox regression., Results: Among 800 patients, 35 (4.4%) underwent EAR, of whom 7 (7/35, 20.0%) experienced HA complications after the initial anatomical reconstruction and required EAR during reoperation. Patients who underwent EAR (n = 2/35, 5.7%) had a similar rate of HA complications compared with those who underwent anatomical reconstruction (n = 46/772, 5.9%, P = 0.699). EAR was a significant risk factor for bile leakage (odds ratio [OR], 4.167; 95% confidence interval [CI], 1.928-9.006; P < 0.001) along with multiple bile ducts (OR, 1.606; 95% CI, 1.022-2.526; P = 0.040) and hepaticojejunostomy (OR, 4.108; 95% CI, 2.190-7.707; P < 0.001). However, EAR had no statistical relationship to biliary stricture-free survival (hazard ratio [HR], 1.602; 95% CI, 0.982-2.613; P = 0.059), graft survival (HR, 1.745; 95% CI, 0.741-4.109; P = 0.203), or overall survival (HR, 1.405; 95% CI, 0.786-2.513; P = 0.251). HA complications were associated with poor biliary stricture-free survival (HR, 2.060; 95% CI, 1.329-3.193; P = 0.001), graft survival (HR, 5.549; 95% CI, 2.883-10.681; P < 0.001), and overall survival (HR, 1.958; 95% CI, 1.195-3.206; P = 0.008)., Conclusion: Extra-anatomical HA reconstruction during living donor LT was not a risk factor for biliary stricture, graft failure, or overall survival.

Background: To analyze the risk factors affecting the development of infection in artificial vascular grafts (AVGs) used for reconstruction of middle hepatic vein (MHV) tributaries in living donor liver transplantation (LDLT)., Methods: Between January 2009 and January 2018, 1253 right lobe LDLTs were performed at our Transplant Institute, and MHV tributaries of the 640 right lobe liver grafts were reconstructed with AVG. Reconstructed MHV tributaries were removed due to AVG infection in 25 of these patients (case group; n = 25). To determine risk factors for AVG infection, right lobe LDLT patients without AVG infections were selected as control group (n = 615). Both groups were compared about demographic parameter, transcystic catheter usage, bile leakage, type of biliary anastomosis (duct-to-duct, telescopic duct-to-duct), number of graft biliary duct (=1 versus >1), number of biliary anastomosis (=1 versus >1), AVG thrombosis, AVG types (Dacron versus polytetrafluoroethylene). Univariate analyses were used for comparison of different variables, and variables with P ≤ 0.20 were taken into logistic regression model., Results: Univariate analysis shows that statistically significant differences were found between groups regarding bile leakage (P < 0.001), graft thrombosis (P = 0.002), transcystic catheter (P = 0.049), and AVG types (P = 0.013). Variables with P ≤ 0.20 were taken into logistic regression model. Multivariate analysis shows that bile leakage (odds ratio, 13.3) and AVG thrombosis (odds ratio, 9.8) were determined as independent and strong risk factors for development of AVG infection., Conclusions: This study revealed that bile leakage and graft thrombosis are independent and strong risk factors for infections of AVGs used for anterior sector drainage reconstruction.