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Objective: Unusual clinical course Background: In living-donor liver transplantation, biliary complications are considered an Achilles' heel. Consequently, various attempts have been made to reduce their incidence, and multiple innovations in surgical techniques have been reported. We herein report a case involving an intraoperative ultrasound cholangiogram in the recipient's abdominal cavity after reperfusion of the graft. Case Report: A 39-year-old male patient with decompensated alcoholic liver cirrhosis was admitted to our hospital for living-donor liver transplantation. The donor was his younger brother. Preoperative magnetic resonance cholangiopancreatography revealed no evidence of biliary anatomical variance; this could have been problematic when donating the left lobe graft. Intraoperative cholangiography showed that the left hepatic duct was sufficiently long for division, guaranteeing donor safety. Back-table observation of the bile duct revealed 3 orifices; of these, the central orifice was very small, and the corresponding bile duct was not evident on intraoperative cholangiography in donor surgery. After an injection of perfluorobutane microbubbles (Sonazoid) diluted 1000-fold into the small central orifice, the bile duct of segment 4 (B4) was clearly visualized with an intraoperative ultrasound cholangiogram. The off-label use of Sonazoid was approved by Nagasaki University Hospital. Based on this finding, we determined that all 3 openings required reconstruction and reconstructed them using a telescope reconstruction method. Conclusions: We verified that intraoperative ultrasound cholangiogram is useful as a tool to confirm the anatomy of the bile duct when it is not revealed through other evaluation techniques; hence, it is a method that transplant surgeons should be familiar with. [ABSTRACT FROM AUTHOR]

Background: While single-incision laparoscopic cholecystectomy (SILC) has gained more popularity in recent years, its application to elderly patients needs further evaluation. Few SILC studies regarded this rapidly growing vulnerable population, and single-incision laparoscopic common bile duct exploration (SILCBDE) was never mentioned. We conducted an observational study of 146 routine SILCBDE to address this issue. Methods: One hundred forty-six consecutive patients underwent SILCBDE with concomitant cholecystectomies during a period of 6 years (July 2012–June 2016 and July 2018–July 2020). Forty patients with an age of 65 years or older were the study target. Characteristics and operative outcomes were compared with the remaining 106 younger patients by retrospective chart review. The primary outcomes include complications and mortality, while the secondary outcomes contain intraoperative blood loss, operative time, procedural conversions, postoperative length of hospital stay, and bile duct stone recurrence. Results: There was no mortality. The bile duct stone clearance rate was 98.6%. The elderly group had higher American Society of Anesthesiologists (ASA) scores, higher comorbidity rate, higher acute cholangitis rate, lower completion intraoperative cholangiography (IOC) rate, longer operative time, more blood loss, longer postoperative hospital stay (p <.001), longer total hospital stay (p <.001), higher procedural conversion rate (p <.05), higher complication rate (p <.001), and the exclusive open conversion (2.5%). The difference in complications derived from Clavien–Dindo grade I. Conclusion: Routine SILCBDE with concomitant cholecystectomy by experienced surgeons is safe and efficacious for elderly patients as for younger patients. Randomized controlled trials are anticipated. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic cholecystectomy is performed very commonly but laparoscopic common bile duct exploration (LCBDE) is performed infrequently. We aimed to determine the most significant barriers to performing LCBDE and to identify the highest yield interventions to facilitate adoption. Methods and procedures: A national survey was designed by content experts, who regularly perform LCBDE. The survey was distributed by email to the Society of American Gastrointestinal and Endoscopic Surgeons and the American Association for the Surgery of Trauma memberships. Non-U.S. surgeon responses were excluded. Descriptive statistics were used to analyze the results. Results: Seven hundred twenty six practicing surgeons responded to the survey, 543 of which were US surgeons who perform laparoscopic cholecystectomy. Only 27% of respondents preferred to manage choledocholithiasis with LCBDE. Their technique of choice was choledochoscopy (70%). Despite this, 36% of surgeons did not have access to a choledochoscope or were unsure if they did. Seventy percent of surgeons who performed LCBDE did not have supplies readily available in a central stocking location. Only 8.5% of surgeons agreed that routine LCBDE would impact their referral relationship with gastroenterology. About half the respondents (47%) considered LCBDE worth the time, but only 25% knew about reimbursement for the procedure. Almost all (85%) of surgeons understood that LCBDE results in shorter length of stay compared to ERCP. Conclusions: Only a quarter of the surgeons performing cholecystectomy perform LCBDE. Multiple barriers contribute to low LCBDE utilization. Increasing availability of appropriate equipment, a dedicated supply cart, and teaching fluoroscopic LCBDE interventions may address limitations and increase adoption. These efforts may also increase efficiency, minimizing perceived time and skill restraints. Although many surgeons understand LCBDE decreases length of stay, they are unaware of surgeon-specific LCBDE financial benefits. Systematically addressing these barriers may increase LCBDE adoption, improve patient care, and decrease healthcare costs. [ABSTRACT FROM AUTHOR]

Background: There is controversy about whether intraoperative cholangiogram (IOC) should be performed routinely during laparoscopic cholecystectomy for patients with acute biliary pancreatitis, given significant false positive and negative rates and increased resource utilization. The aim of this study was to clarify the role of IOC in cases of mild biliary pancreatitis in patients undergoing index admission cholecystectomy, its impact on patient outcomes, and the impact of blood tests, imaging, and preoperative intervention on the detection of choledocholithiasis.Methods: A retrospective review of all patients presenting with acute mild biliary pancreatitis between January 2006 and December 2019 was conducted. Data collected included patient demographics, serum chemistry, IOC, and Endoscopic Retrograde Cholangiopancreatography (ERCP) findings, imaging findings, length of stay, operative length, and long-term follow-up outcomes.Results: 284 patients met the inclusion criteria for the study. The overall false positive IOC rate was 7.4%. Worsening bilirubin trend was a positive predictive value (PPV) for positive IOC and ERCP outcomes with a relative risk of 2.93 (P < .01) and 2.32 (P = .013), respectively. Improving preoperative bilirubin trend had a significant negative predictive value in IOC with a relative risk of .59 (P = .02). Positive IOC was shown to significantly increase operative length with a relative risk of 2.03 (P < .001).Discussion: A rising preoperative bilirubin is a predictor of a positive IOC and patients with normalizing bilirubin levels or a preoperative ERCP are less likely to have choledocholithiasis. These features may be used to select patients that would benefit from an IOC for index admission cholecystectomy. [ABSTRACT FROM AUTHOR]

Background: Preoperative recognition of the anatomy of caudate biliary branches is important for the safe and complete resection of perihilar cholangiocarcinoma (PHC). In the present study, we identified these branches using an endoscopic nasobiliary drainage tube (ENBD). Methods: Between January 2012 and October 2022, 89 patients with suspected PHC underwent computed tomographic (CT) cholangiography through ENBD and caudate biliary branching patterns were examined. Multidetector raw CT (MDCT) scans on 85 patients with PHC without biliary drainage were also investigated. The caudate biliary branches detected by each modality were evaluated. Results: ENBD‐CT cholangiography detected 206 caudate branches (2.44 branches/patient), while MDCT identified 62 branches (0.78 branches/patient). ENBD‐CT cholangiography showed that 89 caudate branches drained into the left hepatic duct (LHD), 87 into the posterior hepatic duct (Bpost), and 30 into the right hepatic duct. LHD and Bpost were the common roots of the caudate branches. Some branches (20%) joined the contralateral hepatic duct across the left–right border, but not the anterior hepatic duct or infraportal‐type Bpost. Conclusions: ENBD‐CT cholangiography clearly showed the caudate biliary branches in patients with PHC after biliary drainage. [ABSTRACT FROM AUTHOR]

Background: To potentially lessen injuries and associated complications, fluorescence cholangiography has been suggested as a technique for enhancing the visualization and identification of extrahepatic biliary anatomy. The most popular way to administer indocyanine green (ICG) is intravenously, as there is currently little data on ICG injections directly into the gallbladder. In order to visualize extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC), we compared the two different ICG administration techniques. We also examined variations in visualization time, as well as the effectiveness, benefits, and drawbacks of each modality. Methods: In this prospective randomized clinical study, 60 consecutive adult patients with chronic and acute gallbladder disease were included. Our study conducted from 2022 to 2024 in Surgical Department of Theodor Bilharz Research Institute. Thirty patients underwent LC with intravenous ICG administration (IV-ICG), thirty patients received a direct injection of gallbladder through transhepatic ICG (IC-ICG) and Preoperative, intraoperative, and postoperative patient data were examined. Results: In terms of their perioperative and demographic features, the groups were similar. Without a statistically significant difference, the IV-ICG group's total operating time was less than that of the IC-ICG group (p 0.140). Compared to the transhepatic IC-ICG method, IV-ICG was more accurate in identifying the duodenum and the common hepatic duct (p = 0.029 and p = 0.016, respectively). In the transhepatic IC-ICG and IV-ICG groups, the cystic duct could be identified prior to dissection in 66.6% and 73.3% of cases, respectively, and this increased to 86.6% and 93.3% following dissection. In the transhepatic IC-ICG group, the common bile duct was visible in 93.3% of cases; in the IV-ICG group, it was visible in 90% of cases. Two cases in the IC-ICG group and every case following IV-ICG administration had liver fluorescence (6.6% versus 100%; p < 0.001). Conclusion: The current study shows that for both administration methods, ICG-fluorescence cholangiography can be useful in identifying the extrahepatic biliary anatomy during Calot's triangle dissection. By avoiding hepatic fluorescence, the transhepatic IC-ICG route can increase the bile duct-to-liver contrast with less expense and no risk of hypersensitivity reactions than the intravenous ICG injection method. We recommend to use both techniques in case of acute cholecystitis with cystic duct obstruction. In cases of liver cirrhosis, we recommend transhepatic IC-ICG as IV-ICG is limited. [ABSTRACT FROM AUTHOR]

Objectives: The current study compared potential risks, complications, and the impact on clinical outcomes among elderly and younger patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Methods: Procedure-related complications, risk factors, and clinical outcomes following complications in elderly patients (aged ≥75 years) and younger who underwent biliary ERCP were evaluated. Results: Median age of 63 (48–74) of 1164 patients who underwent biliary ERCP for the first time, and 266 (22.8%) were elderly. Comorbidities were statistically significant (81 [30.5%] versus 78 [8.7%], p < 0.001), and periampullary diverticulum (PAD) was detected more commonly in the elderly group (79 [29.7%] vs. 103 [11.5%], p < 0.001). There was no statistical difference in cannulation technique, cannulation time, and cannulation success in both groups, while the total ERCP procedure time was higher in the elderly group (22 [16–29] vs. 20 [14–29], p = 0.030). Regarding the procedure-related complications, there was no statistically significant difference between the two groups (26 [9.8%] vs. 71 [7.9%], p = 0.292). In the case of complications, the length of hospitalization stay was statistically longer in the elderly group. Moreover, the elderly had a longer length of hospitalization, experiencing pancreatitis and a higher probability of developing moderate/severe pancreatitis. In multivariate and univariate analysis, prolonged cannulation time was found to be an independent risk factor in patients ≥75 years of age. Conclusions: This study showed that while ERCP-related complication rates in elderly patients are comparable to younger patients, it can be associated with worse outcomes following the complication and prolonged length of hospitalization. [ABSTRACT FROM AUTHOR]

Background: Endoscopic retrograde cholangiopancreaticography (ERCP) is the standard endoscopic procedure for the diagnosis and treatment of diseases of the pancreas and bile ducts. Cholangioscopy provides direct visualization of the bile ducts. It offers the possibility of more detailed diagnostic and therapeutic indications. Today, cholangioscopy is often performed as a single-operator (SOC) procedure. Objectives: We were interested in the clinical efficacy of our SOC procedure in comparison with published studies, and performed this retrospective data analysis of all our consecutive patients from 2016 to 2022 to analyze the feasibility, safety, and efficacy of SOC. Design and Methods: A retrospective single-center analysis of patients undergoing SOC at a tertiary center from 2016 to 2022 (N = 196) was performed. Demographic data, indication for SOC, exam-specific data, efficacy, and complications were included. Sensitivity and specificity for diagnosing indeterminate biliary strictures were calculated. Results: The most common indications for SOC were indeterminate biliary strictures (n = 117; 60%), treatment of biliary stones (n = 45; 23%), and other indications (n = 34; 17%), for example, foreign body removal or intraoperative SOC. In 97% of the SOC (n = 191), the procedure was technically successful. The diagnostic or therapeutic goal was achieved in 91% of SOC (n = 173). In the subgroup where the SOC result was confirmed by subsequent surgery (n = 93), sensitivity was 86%, specificity 99%, and SOC treatment of stones was successful in 89%. Complications occurred in (20%; n = 37). The majority of these patients (n = 18; 10%) had minor bleeding requiring no intervention. Conclusion: SOC is an effective and safe procedure that should be the standard of care when primary diagnostic and/or therapeutic ERCP has failed. The sensitivity and specificity for determining the dignity of biliary strictures and the efficacy for the treatment of difficult-to-treat stones are reproducibly very high. Plain language summary: Feasibility, safety and efficacy of endoscopic biliary endoscopy: a retrospective Single Center study Imaging the bile duct with contrast medium and fluoroscopy as part of endoscopic retrograde cholangiopancreaticography (ERCP) is the gold standard. However, direct visualization of the bile duct using a small camera on a second endoscope (cholangioscope) opens up further diagnostic and therapeutic possibilities. This study is a retrospective study covering the years 2016-2022, with a total of 196 patients. Demographic data, indication for SOC, exam specific data, efficacy, complications were included. The most common indications for direct biliary endoscopy were indeterminate biliary strictures (n=117; 60%), treatment of biliary stones (n=45; 23%) and other indications (n=34; 17%), e.g. foreign body removal or intraoperative biliary endoscopy. In 97% of the direct biliary endoscopy (n=191), the procedure was technically successful. The diagnostic or therapeutic goal was achieved in 91% of direct biliary endoscopy (n=173). In summary, direct biliary endoscopy is an effective and safe procedure that should be the standard of care when primary diagnostic and/or therapeutic ERCP has failed. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Although cytologic examination of biliary stricture brushings obtained by endoscopic retrograde cholangiopancreatography is commonly used for diagnosing malignant biliary strictures (MBSs), it has low sensitivity. Several new brushes have capabilities that are still being debated. We have developed a novel brush working from conventional back-and-forth movement to rotation in situ (RIS) that may be more efficient for MBS sampling. We aimed to compare the MBS detection sensitivity of our RIS brush with that of the conventional brush. METHODS: In this multicenter prospective study, we enrolled patients who underwent endoscopic retrograde cholangiopancreatography for suspected MBSs involving biliary stricture brushings obtained using our RIS brush. The historical control group consisted of the 30-brushing arm of our previous randomized trial (patient inclusion, 2018-2020) that used the study design in the same centers and with the same endoscopists as were used in this study. The primary outcomewas to compare the sensitivity and specificity of detecting MBSs by cytologic evaluation of biliary stricture brushings between the 2 groups. RESULTS: We enrolled 155 patients in the intent-to-treat analysis. Using the same number of brushing cycles, the RIS brush showed a higher sensitivity than the conventional brush (0.73 vs 0.56, P 5 0.003). In perprotocol population, the sensitivity was also higher in the RIS brush group than in the conventional brush group (0.75 vs 0.57, P 5 0.002). Multivariate analysis revealed that the RIS brush was the only predictive factor for MBS detection. No significant differences were observed in procedure-related complications between the 2 groups. DISCUSSION: The RIS brush was a promising tool for effective and safe MBS sampling and diagnosis. Further randomized studies are warranted to confirm our results (Chictr.org.cn, identifier: ChiCTR2100047270). [ABSTRACT FROM AUTHOR]

This article provides an overview of laparoscopic cholecystectomy (LC), a minimally invasive procedure for gallbladder removal. LC has become a widely accepted and safe alternative to open cholecystectomy (OC), although complications such as bile duct injury can still occur. The article also explores the use of LC for acute cholecystitis and laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis, as well as alternative procedures for challenging cases. The need for further research on preoperative assessment methods and the use of new technologies in LC is highlighted. Additionally, the article discusses studies comparing different surgical techniques for common bile duct stone removal, finding no significant difference in success rates but variations in adverse events and hospital stay duration. The authors recommend laparoscopic surgery for pediatric patients but note insufficient evidence to support its use in adults. The text concludes by emphasizing the importance of training in laparoscopic common bile duct exploration and its potential benefits. [Extracted from the article]

Background: Patients with acute cholecystitis (AC) presenting with unfavorable systemic or local conditions are often managed with percutaneous cholecystostomy (PC) as a temporary measure. The clinical outcomes of interval cholecystectomy following PC remain unclear. The aim of the study was to identify the association between the timing of cholecystectomy following PC for AC and perioperative complication rates at interval cholecystectomy. We hypothesized that there would be a specific time interval to cholecystectomy associated with lower risk for adverse events. Methods: This was a retrospective (2018–2020) multicenter study at 8 participating hospital systems of adult patients with AC, managed with PC and interval cholecystectomy. Demographics, comorbidities, treatment details, and outcomes were examined. Patients were grouped based on quartiles for timing of surgery after PC (< 7, 7–9, 10–13, > 13 weeks). The primary outcome was a composite endpoint of bile duct injury, reoperation, readmission, image-guided intervention, endoscopic intervention, conversion to open surgery, or death. Results: There were 188 patients with a median age of 66 years with AC classified as mild (41%), moderate (47%), and severe (12%). Median days from PC to surgery were 65 (Q1 = 48, Q3 = 91). Laparoscopic cholecystectomy (89.9%) was the most commonly planned approach (robotic 6.4%, 3.7% open) and 28 (14.9%) were converted to open. The composite endpoint was reported in 51 patients (27.1%). A biliary injury occurred in 7 (3.7%) patients. Time to surgery and intraoperative drain placement were independently associated with the composite outcome. Cholecystectomy within 7 weeks of PC was associated with decreased risk (OR = 0.36, 95% CI 0.13–0.97) of the composite endpoint, compared to patients undergoing surgery > 13 weeks after PC. Conclusion: Timing of surgery following PC was associated with procedural outcomes. Patients undergoing surgery before 7 weeks experienced significantly less morbidity than patients having delayed cholecystectomy. These results should be considered in patient selection and management after PC. [ABSTRACT FROM AUTHOR]

Objectives: To describe the MR features and prognosis of patients with an uncommon complication of primary sclerosing cholangitis (PSC) characterized by a spontaneous perforation of the common bile duct (CBD) resulting in a peri-biliary collection and a pseudo-cystic appearance of the CBD. Methods: A single-center cohort of 263 patients with PSC who had at least two MRIs between 2003 and 2022 and a minimum follow-up of 1 year was retrospectively analyzed. MRI data (characteristics of CBD perforation and MR features of PSC) and clinical data were assessed. Analysis of survival without liver transplantation according to type of PSC (classical or CBD spontaneous perforation) was performed according to the Kaplan–Meier method and the curves were compared using the Log-Rank test. Results: A total of nine (3.4%) PSC patients (5 males) had perforation of the CBD with a median age at diagnosis of 18 years compared to 33 years for the control group (p = 0.019). The peri-biliary collections were variable in appearance (fusiform or pedunculated), with a diameter ranging from 5 to 54 mm. All nine patients showed intra- and extra-hepatic bile duct involvement, dysmorphia, and high ANALI scores. The clinical course was characterized by numerous complications in most patients, and five patients (56%) underwent liver transplantation at a median time of 5 years from diagnosis, compared to 40 patients (16%) in the control group (p = 0.02). Conclusion: The spontaneous perforation of the common bile duct is an uncommon complication of primary sclerosing cholangitis that affects young patients and is associated with a poor prognosis. Clinical relevance statement: This uncommon complication of primary sclerosing cholangitis with perforation of the common bile duct resulting in a peri-biliary collection and a pseudo-cystic appearance of the common bile duct is characterized by a poor prognosis in younger patients. Key Points: • Among 263 patients with primary sclerosing cholangitis (PSC), nine patients (3.6%) had an uncommon complication characterized on MRI by perforation of the common bile duct (CBD). • This perforation of the CBD was responsible in all nine cases for the formation of a peri-biliary collection, giving a pseudo-cystic appearance to the CBD. • The spontaneous perforation of the common bile duct is an uncommon complication of primary sclerosing cholangitis that affects young patients with a poor prognosis. [ABSTRACT FROM AUTHOR]

Background: Bile duct injury (BDI) is one of the most severe complications during cholecystectomy. Early identification of risk factors for BDI may permit risk reduction strategies and inform patient consent. Objective: This study aimed to define patient, provider, and systemic factors associated with BDI; BDI incidence; and short-term outcomes of BDI after urgent cholecystectomy. Methods: Patients who underwent urgent cholecystectomy for acute cholecystitis were retrospectively screened (2020-2022). All patients who sustained BDI were included without exclusions. Demographics, clinical data, and outcomes were collected and compared with descriptive statistics. Results: During the study period, BDI occurred in 4 (0.5%) of 728 patients who underwent urgent cholecystectomy for acute cholecystitis. Most BDI cases (75%) took place overnight or during the weekend. The attending surgeon was almost exclusively (75%) in their first year of practice. BDI was recognized during index operation in 2 cases (50%). Hepatobiliary surgery performed the bile duct repair in all 4 cases. Two complications occurred (50%). All patients were followed by hepatobiliary surgery in the outpatient setting and returned to their baseline level of function within 2 months of hospital discharge. Conclusion: Most BDI occurred in procedures attended by first-year faculty during after hours cholecystectomies, suggesting a role for increased proctorship in early career attendings in addition to in-hours cholecystectomy for acute cholecystitis. The timely return to baseline function experienced by these patients emphasizes the favorable outcomes associated with early recognition of BDI and involvement of hepatobiliary surgery. Further examination with multicenter evaluation would be beneficial to validate these study findings. [ABSTRACT FROM AUTHOR]

Introduction: Preoperative Coronavirus Disease 2019 (COVID-19) infections are associated with postoperative adverse outcomes. However, there is limited data on the impact of postoperative COVID-19 infection on postoperative outcomes of common general surgery procedures. Objective: To evaluate the impact of postoperative COVID-19 diagnosis on laparoscopic cholecystectomy outcomes. Methods: Patients with symptomatic cholelithiasis, acute cholecystitis, or gallstone pancreatitis who underwent laparoscopic cholecystectomy with or without intraoperative cholangiogram were identified using the 2021 National Surgical Quality Improvement Program (NSQIP) database. Patients were categorized into two groups: patients with and without a postoperative COVID-19 diagnosis. Coarsened Exact Matching was used to match the groups based on preoperative risk factors, and outcomes were compared. Results: A total of 47,948 patients were included. In the aggregate cohort, 31% were male, and mean age was 50 years. Age, BMI, smoking, COPD, CHF, preoperative sepsis, and ASA class were significantly different between the two groups. After matching, there were no differences in characteristics. 30-day morbidity (OR = 2.7, 95% CI 1.4-5.1), pneumonia (OR = 5.0, 95% CI 1.7-15.0), DVT (OR = 8.22, 95% CI 1.0-66), reoperation (OR = 9.3, 95% CI 1.2-73.8), and readmission (OR = 4.8, 95% CI 2.3-10.1) continued to be significantly worse in the matched cohort. Conclusion: Postoperative COVID-19 infection was associated with worse outcomes after laparoscopic cholecystectomy. These findings suggest that even postoperative COVID-19 diagnosis increases the risk for adverse outcomes in patients recovering from laparoscopic cholecystectomy and may indicate that precautions should be taken and new COVID-19 infections even after surgery should be closely monitored. [ABSTRACT FROM AUTHOR]

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Recurrent cholangitis, intrahepatic stones and biliary and anastomotic strictures are common complications after Roux-en-Y hepaticojejunostomy. The surgically altered anatomy makes management of these complications with endoscopic retrograde cholangiopancreatography technically difficult. We present a case of recurrent cholangitis in a 25-year-old woman with a prior hepaticojejunostomy. Intrahepatic stones, biliary strictures and hepaticojejunostomy strictures were treated using a combined percutaneous transhepatic cholangiography and cholangioscopy approach over several interventions. Minimally invasive, multidisciplinary approach to the management of intrahepatic biliary calculi and stricture after hepaticojejunostomy can be considered in cases where traditional endoscopic retrograde cholangiopancreatography intervention is too technically difficult.

Background: Liver transplantation in pediatric patients is a crucial intervention for treating end-stage hepatic diseases. Despite significant advances in surgical techniques and postoperative care, complications remain a substantial challenge in this population. Biliary stones, an infrequent complication, present challenges in this context. Given the impossibility of endoscopic treatments, different strategies have been explored to address post-liver transplantation gallstones in children by implementing percutaneous treatment with intraductal lithotripsy. Case presentation: A 7-year-old Latin patient, who had a diagnosis of biliary atresia at the age of 2, underwent a liver transplant from a living donor. However, 4 months after the transplant, the patient experienced recurring episodes of cholangitis. Cholangioresonance revealed intrahepatic lithiasis and anastomotic stenosis. Attempted gallstone removal through percutaneous cholangiography proved unsuccessful, as multiple peripheral stones in all ducts remained immobile. Subsequently, a percutaneous endoscopic cholangioscopy using the SpyGlass Discover system for visual examination of the bile ducts + electrohydraulic lithotripsy was performed, effectively removing the stones without any complications. Conclusions: Percutaneous cholangioscopy with intraductal lithotripsy enables accurate identification and extraction of intrahepatic stones without the need for surgical intervention. This method proves to be a valuable alternative in addressing post-transplant biliary stone. In our case, it was performed on a pediatric patient who underwent liver transplantation, which makes it interesting and relevant as there is currently insufficient literature on this approach in such cases in this population. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to explore the application value of three-dimensional (3D) visualization technology in the early surgical repair of bile duct injury during laparoscopic cholecystectomy (LC). Methods: A retrospective analysis was conducted on the clinical data of 15 patients who underwent early surgical repair of bile duct injury during LC with the assistance of 3D visualization technology at the Hepatobiliary Surgery Department of Ningxia Hui Autonomous Region People's Hospital from January 2019 to December 2022. Postoperative efficacy and long-term follow-up outcomes were summarized. Results: Before the repair surgery, 15 cases of bile duct injury during LC were evaluated using 3D visualization technology according to the Strasberg-Bismuth classification: 2 cases of type C, 4 of type E1, 3 of type E2, 3 of type E3, and 3 of type E4. Intraoperative findings were consistent with the 3D visualization reconstruction results, and all patients successfully underwent hepaticojejunostomy using Roux-en-Y anastomosis guided by the 3D visualization navigation. The time interval between LC and bile duct repair surgery ranged from 5 to 28 (14.2 ± 9.7) days. The surgical time was between 120 and 190 (156.40 ± 23.92) min, and estimated blood loss ranged from 80 to 250 (119.66 ± 47.60) mL. The length of hospital stay ranged from 12 to 25 days (median: 16 days). One patient experienced mild bile leakage after the operation, which healed with conservative treatment. All patients were followed up for 12–56 months (median: 34 months) without any loss to follow-up. During the follow-up period, no complications, such as anastomotic stricture or stone formation, were observed. Conclusion: The application of 3D visualization technology for preoperative evaluation and intraoperative navigation can accurately and effectively facilitate early surgical repair of bile duct injury during LC and has clinical value for promotion and application. [ABSTRACT FROM AUTHOR]

Background: Biliary dilatation without obvious etiology on cross sectional imaging warrants further investigation. This study aimed to assess yield of endoscopic ultrasound in providing etiologic diagnosis in such situation. Methods: Prospective cohort of consecutive patients with biliary dilatation & non diagnostic computed tomography (CT) and /or magnetic resonance imaging (MRI) underwent endoscopic ultrasound (EUS) with/without fine needle aspiration cytology (FNAC) and were followed clinically, biochemically with/without radiology for up to six months. The findings of EUS were corroborated with histopathology of surgical specimens and endoscopic retrograde cholangiography (ERCP) findings in relevant cases. Results: Median age of 121 patients completing follow up was 55 years. 98.2% patients were symptomatic and median common bile duct (CBD) diameter was 13 mm. EUS was able to identify lesions attributable for biliary dilatation in (67 out of 121) 55.4% cases with ampullary neoplasm being the commonest (29 out of 67 i.e. 43%). Multivariate logistic regression analysis identified jaundice as the predictor of positive diagnosis on EUS, of finding ampullary lesion and pancreatic lesion on EUS. EUS had sensitivity, specificity, positive predictive value and diagnostic accuracy of 95.65%, 94.23%, 95.65% and 95.04% respectively in providing etiologic diagnosis. Threshold value for baseline bilirubin of 10 mg%, for baseline CA 19.9 of 225 u/L and for largest CBD diameter of 16 mm were determined to have specificity of 98%, 95%, 92.5% respectively of finding a positive diagnosis on EUS. Conclusion: EUS provides considerable diagnostic yield with high accuracy in biliary dilatation when cross sectional imaging fails to provide etiologic diagnosis. [ABSTRACT FROM AUTHOR]

Background: Drains are used to reduce abdominal collections after procedures where such risk exists. Using abdominal drains after cholecystectomy has been controversial since the open surgery era. Universally accepted indications and agreement exist that routine drainage is unnecessary but the role of selective drainage remains undetermined. This study evaluates the indications and benefits of sub-hepatic drainage in patients undergoing laparoscopic cholecystectomy (LC) and bile duct exploration (BDE) in a specialist unit with a large biliary emergency workload. Methods: Prospectively collected data from 6,140 LCs with a 46.6% emergency workload over 30 years was reviewed. Demographic factors, pre-operative presentations, imaging and operative details in patients with and without drains were compared. Sub-hepatic drains were inserted after all transductal explorations, subtotal cholecystectomies, almost all open conversions and 94% of LC for empyemas. Adverse or beneficial postoperative drain-related outcomes were analysed. Results: Abdominal drains were utilised in 3225/6140 (52.5%). Patients were significantly older with more males. 59.4% were emergency admissions. Preoperative imaging showed thick-walled gallbladders in 25.2% and bile duct stones or dilatation in 36.2%. At operation they had cystic duct stones in 19.8%, acute cholecystitis, empyema or mucocele in 28.4% and operative difficulty grades III or higher in 59%. 38% underwent BDE, 5.4% had fundus-first dissection and the operating times were longer (80 vs.45 min). Drain related complications were rare; 3 abdominal pains after anaesthetic recovery settling when drains were removed, 2 drain site infections and one re-laparoscopy to retrieve a retracted drain. 55.8% of 43 bile leaks and 35% of 20 other collections in patients with drains resolved spontaneously. Conclusions: The utilisation of drains in this study was relatively high due to the high emergency workload and interest in BDE. While drains allowed early detection of bile leakage, avoiding some complications and monitoring conservative management to allow early reinterventions, the study has identified operative criteria that could potentially limit drain insertion through a selective policy. [ABSTRACT FROM AUTHOR]

Background: Biliary reconstruction technique during liver transplant (LT) for primary sclerosing cholangitis (PSC) remains controversial. This study aimed to evaluate the incidence of biliary complications in patients with PSC having a duct‐to‐duct (DD) anastomosis or Roux‐en‐Y hepaticojejunostomy (HJ). Methods: A retrospective medical record review of patients with PSC undergoing LT at a single center between June 1st, 2000 and December 31st, 2022 was performed. Primary and secondary endpoints were the incidence of biliary strictures (anastomotic [BAS] and non‐anastomotic strictures [NAS]) and non‐stricture complications, respectively. Univariable and multivariable regression analyses were performed to identify associations with BAS formation. Patient survival was assessed using a Kaplan–Meier curve. Results: From 105 transplants performed for 101 patients, 54 (51.4%) and 51 (48.5%) received DD and HJ anastomoses. Mean recipient age and follow‐up was 47 ± 13 years and 98 ± 69 months. BAS was more common (48.1% vs. 27.5%, OR 2.45, 95% CI 1.09–5.54, p = 0.03) and occurred earlier (4.8 months, IQR 2.3–13.1 vs. 41.8 months, IQR 7.2–88.7, p = 0.001) in the DD than the HJ group. NAS (seen in 36.2% of transplants) had a comparable incidence (p = 0.53) in HJ (38.9%) and DD (33.3%) groups. No difference was seen between cohorts regarding time to NAS, requirement for extended biliary dilatation programs (clinically significant biliary stricture), bile leak, and graft failure. On multivariable analysis, only the anastomotic technique was associated with BAS (DD adjusted OR 3.00, 95% CI 1.19–7.56, p = 0.02). Conclusion: In carefully selected patients with PSC, DD anastomosis yielded similar outcomes to HJ anastomosis after liver transplantation. [ABSTRACT FROM AUTHOR]

Objectives This study aims to evaluate whether stent removal through endoscopic retrograde cholangiopancreatography (ERCP) with balloon sweeps is necessary or whether stent removal by forward-viewing gastroscope without cholangiogram is sufficient. Materials and Methods A prospective, single-center study was conducted from April 2022 to March 2023 for 1 year. Adult patients with choledocholithiasis who underwent common bile duct (CBD) clearance and CBD stenting followed by cholecystectomy were included. Then, they underwent CBD stent removal either by gastroscope directly or by side-viewing endoscopy with balloon sweeps and occlusion cholangiogram. Recurrence of stones and complications after stent removal were studied in both groups. Results Forty-seven patients were enrolled in the final study. A total of 64% of patients (n = 30) underwent CBD stent removal followed by balloon sweeps and cholangiogram, and the remaining 34% (n = 17) patients underwent direct stent removal. Time taken for the procedure was more in the balloon sweeps group compared with the direct stent removal group and was statistically significant. No statistically significant adverse events were seen in both groups. Conclusion Patients who underwent CBD stenting for choledocholithiasis after cholecystectomy can safely undergo stent removal using a gastroscope rather than be subjected again to ERCP. This will significantly reduce the duration, unplanned adverse events, and cost of ERCP. [ABSTRACT FROM AUTHOR]

• We studied 3 cases of HAS after liver transplantation. • HAS may not be resolved with conventional treatment using a plastic stent. • We evaluated the usefulness of fully-covered self-expandable metal stents (FCSEMSs). • FCSEMS placement may be effective and safe for HAS after liver transplantation. • Magnetic resonance cholangiopancreatography should identify HAS before cholangiography. We prospectively evaluated 3 cases regarding the usefulness of fully-covered self-expandable metal stents (FCSEMSs) for hepaticojejunostomy anastomotic stricture (HAS) after living donor liver transplantation (LDLT), which could not be resolved with conventional treatment using a plastic stent. All patients underwent LDLT with Roux-en-Y reconstruction; therefore, a short-type double-balloon enteroscope was used for the endoscopic procedures. HAS was observed on enteroscopic view of endoscopy in patients 1 and 2, and cholangiography revealed dilatation of the intrahepatic bile duct. The FCSEMS was successfully placed without the report of adverse events. The FCSEMS was removed after 16 weeks, and the HAS improved in both patients. In addition, stone clearance was also achieved in patient 2. On the other hand, FCSEMS was not placed in patient 3 because there was no indication of FCSEMS placement due to the multiple segmental biliary strictures (pruned-tree appearance on cholangiography). Subsequent deceased-donor liver transplantation confirmed recurrent primary sclerosing cholangitis. In this case, magnetic resonance cholangiopancreatography (MRCP) was not performed prior to cholangiography to rule out PSC recurrence. FCSEMS placement may be effective and safe for HAS after LDLT, which is not resolved with conventional treatment using a plastic stent. MRCP should be used to identify HAS prior to invasive cholangiography. [ABSTRACT FROM AUTHOR]

Contrast-enhanced T1-weighted magnetic resonance cholangiography (CE-T1-MRC) after gadoxetate disodium administration can be used for preoperative evaluation of the bile ducts in live liver donors. This study aimed to determine whether CE-T1-MRC with 3-hour delayed imaging improves bile duct visualization both qualitatively and quantitatively compared with 20-minute delayed imaging in potential living liver donors. We retrospectively identified 33 potential living liver donors (mean age, 30.1 years; 18 men and 15 women) who underwent preoperative CE-T1-MRC with both 20-minute delayed and 3-hour delayed imaging in a single session. The radiologist scored biliary visualization for right and left hepatic ducts (RHD and LHD), their secondary confluences and segmental bile ducts, common hepatic duct (CHD), and cystic duct (CD), and measured relative contrast ratio (rC) and relative signal intensity (rS) for RHD, LHD, and CHD. The data were analyzed using Wilcoxon's signed-rank test and paired t-test. In qualitative analysis, duct visualization scores for RHD and LHD, their secondary confluences and segmental bile ducts, CHD, and CD were significantly higher on CE-T1-MRC with 3-hour delayed imaging than with 20-minute delayed imaging (all, P ≤.046). In quantitative analysis, both rC and rS of RHD, LHD, and CHD were significantly higher on CE-T1-MRC with 3-hour delayed imaging than with 20-minute delayed imaging (all, P <.001). CE-T1-MRC with 3-hour delay imaging improves bile duct visualization both qualitatively and quantitatively in potential living liver donors. [ABSTRACT FROM AUTHOR]

This document contains a collection of abstracts summarizing various research studies related to surgery and patient outcomes. The studies cover a range of topics, including the role of Emergency General Surgery surgeons, prognostic markers for cancer patients, predictive models for surgical site infections, endoscopic histopathology results, and the use of nanoparticles in cancer treatment. Other studies explore topics such as surgical site infections, cholecystectomy in children, remote postoperative surveillance, and the use of inhaled methoxyflurane for abscess drainage. These abstracts provide valuable insights into surgical practices and outcomes, which can inform future research and decision-making in the field of surgery. [Extracted from the article]

Background: Intraoperative laparoscopic ultrasonography (LUS) or intraoperative cholangiography (IOC) can be used for visualisation of the biliary tract during laparoscopic cholecystectomy. The aim of this systematic review was to compare use of LUS with IOC. Methods: PubMed, Embase, the Cochrane Library, and Web of Science were searched (last update: April 2024). PICO: P = patients undergoing intraoperative imaging of the biliary tree during laparoscopic cholecystectomy for gallstone disease; I = intervention: LUS; C = comparison: IOC; O = outcomes: mortality, bile duct injury, retained gallstone, conversion to open cholecystectomy, procedural failure, operation time including imaging time. Included articles were critically appraised using checklists. Conclusions were based on studies without major risk of bias. Meta-analyses were performed using random effects models. Certainty of evidence was assessed according to GRADE. Results: Sixteen non-randomised studies met the PICO. Two before/after studies (594 versus 807 patients) contributed to conclusions regarding mortality (no events; very low certainty evidence), bile duct injury (1 versus 0 events; very low certainty evidence), retained gallstone (2 versus 2 events; very low certainty evidence), and conversion to open cholecystectomy (6 versus 21 events; risk ratio: 0.38 (95% confidence interval: 0.15–0.95); I2 = 0%; low certainty evidence). Seven additional studies, using intra-individual comparisons, contributed to conclusions regarding procedural failure; risk ratio: 1.12 (95% confidence interval: 0.70–1.78; I2 = 83%; very low certainty evidence). No studies reported operation time. Mean imaging time for LUS and IOC, reported in 12 studies, was 4.8‒10.2 versus 10.9‒17.9 min (mean difference: − 7.8 min (95% confidence interval: − 9.3 to − 6.3); I2 = 95%; moderate certainty evidence). Conclusion: It is uncertain whether there is any difference in mortality/bile duct injury/retained gallstone using LUS compared with IOC, but LUS may be associated with fewer conversions to open cholecystectomy and is probably associated with shorter imaging time. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to evaluate the incidence and clinical implications of bile duct changes following multibipolar radiofrequency ablation (mbpRFA) for hepatocellular carcinoma (HCC). Materials and methods: Radiological, clinical, and biological data from consecutive cirrhotic patients who underwent first-line mbpRFA between 2007 and 2014 for uninodular HCC ≤ 5 cm were retrospectively collected. Follow-up imaging was reviewed to identify bile duct changes and factors associated with biliary changes were assessed using multivariable analysis. Baseline and 6-month liver function tests were compared in patients with and without bile duct changes. Complications, cirrhosis decompensation, and survival rates were compared in both groups. Results: A total of 231 patients (mean age 68 years [39-85], 187 men) underwent 266 mbpRFA sessions for uninodular HCC (mean size 26 mm). Of these, 76 (33%) developed bile duct changes (upstream bile duct dilatations and/or bilomas) with a mean onset time of 3 months. Identified risk factors for these changes were the infiltrative aspect of the tumor (p = 0.035) and its location in segment VIII (p < 0.01). The average increase in bilirubin at 6 months was higher in the group with biliary changes (+2.9 vs. +0.4 µg/mL; p = 0.03). There were no significant differences in terms of complications, cirrhosis decompensation at 1 year (p = 0.95), local and distant tumor progression (p = 0.91 and 0.14 respectively), and overall survival (p = 0.4) between the two groups. Conclusion: Bile duct changes are common after mbpRFA for HCC, especially in tumors with an infiltrative aspect or those located in segment VIII. These changes do not appear to negatively impact the course of cirrhosis at 1 year or overall survival. Clinical relevance statement: Bile duct changes following mbpRFA for HCC are relatively common. Nevertheless, they do not raise clinical concerns in terms of complications, deterioration in liver function, or survival rates. Consequently, specific monitoring or interventions for these bile duct changes are not warranted. Key Points: • Bile duct changes are frequently observed after multibipolar radiofrequency ablation for hepatocellular carcinoma, occurring in 33% of cases in our study. • Patients with bile duct changes exhibited a higher increase in bilirubin levels at 6 months but no more cirrhosis decompensation or liver abscesses. • Biliary changes following multibipolar radiofrequency ablation for hepatocellular carcinoma are not alarming and do not necessitate any specific monitoring or intervention. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to clarify the significance of blood culture testing in the postoperative period of pancreatoduodectomy (PD), a highly invasive surgery. Methods: Rates of blood culture sampling and positivity were investigated for febrile episodes (FEs) in patients who underwent PD (2016–2021). FEs were defined as body temperature of 38.0°C or higher occurring on or after the 4th postoperative day. Fever origin was diagnosed retrospectively, and FEs were classified as pancreatic fistula (PF)‐related or PF‐unrelated FEs. Factors correlated with blood culture positivity were explored. Results: Among 339 patients who underwent PD, 99 experienced 202 FEs. Blood culture testing was performed on 160 FEs occurring in 89 patients. The sampling and positivity rates were 79.2% and 17.5%, respectively, per episode and 89.9% and 28.1%, respectively, per patient. Thirty‐six FEs were classified as PF‐related and 124 were classified as PF‐unrelated FEs. The blood culture positivity rate was significantly lower in PF‐related vs. PF‐unrelated FEs (1/36 vs. 27/124, respectively, p = 0.006). The blood culture positivity rate was significantly higher in patients with cholangitis, catheter‐related blood stream infection, and urinary tract infection than PF‐related FEs. Multivariate analysis showed that blood culture positivity was negatively associated with PF‐related FEs and positively associated with accompanying symptoms of shivering, Pitt Bacteremia Score, and preoperative biliary drainage. Conclusions: Patients who underwent PD showed relatively high blood culture positivity rates. Based on these results, it may be possible to distinguish PF‐related and ‐unrelated FEs. [ABSTRACT FROM AUTHOR]

Autoimmune pancreatitis type 2 is a relatively novel entity with some still controversial issues. The current diagnostic algorithm relies on imaging studies and histology. Therapy includes corticosteroids with consequently low risk of relapse in the following year. However, the pathogenesis remains unclear, and data are insufficient for long-term prognosis. We have treated a 17-year-old boy whose autoimmune pancreatitis type 2 was revealed during surgery for a pre-existing biliary tract anomaly with concurrent protozoal infection. We discuss the co-occurrence of these conditions in terms of eventual pathogenesis correlation and combined effect on long-term prognosis. [ABSTRACT FROM AUTHOR]

Fluorescence imaging is a real-time intraoperative navigation modality to enhance surgical vision and it can guide emergency surgeons while performing difficult, high-risk surgical procedures. The aim of this study is to assess current knowledge, attitudes, and practices of emergency surgeons in the use of indocyanine green (ICG) in emergency settings. Between March 08, 2023 and April 10, 2023, a questionnaire composed of 27 multiple choice and open-ended questions was sent to 200 emergency surgeons who had previously joined the ARtificial Intelligence in Emergency and trauma Surgery (ARIES) project promoted by the WSES. The questionnaire was developed by an emergency surgeon with an interest in advanced technologies and artificial intelligence. The response rate was 96% (192/200). Responders affirmed that ICG fluorescence can support the performance of difficult surgical procedures in the emergency setting, particularly in the presence of severe inflammation and in evaluating bowel viability. Nevertheless, there were concerns regarding accessibility and availability of fluorescence imaging in emergency settings. Eighty-seven out of 192 (45.3%) respondents have a fluorescence imaging system of vision for both elective and emergency surgical procedures; 32.3% of respondents have this system solely for elective procedures; 21.4% of respondents do not have this system, 15% do not have experience with it, and 38% do not use this imaging in emergency surgery. Less than 1% (2/192) affirmed that ICG fluorescence changed always their intraoperative decision-making. Precision surgery effectively tailors surgical interventions to individual patient characteristics using advanced technology, data analysis and artificial intelligence. ICG fluorescence can serve as a valid and safe tool to guide emergency surgery in different scenarios, such as intestinal ischemia and severe acute cholecystitis. Due to the lack of high-level evidence within this field, a consensus of expert emergency surgeons is needed to encourage stakeholders to increase the availability of fluorescence imaging systems and to support emergency surgeons in implementing ICG fluorescence in their daily practice. [ABSTRACT FROM AUTHOR]

Purpose: To determine the causes of benign hepaticojejunostomy strictures (BHSs) after pancreaticoduodenectomy (PD) and the outcome of endoscopic retrograde cholangiography (ERC) treatment for BHSs. Methods: A total of 175 patients who underwent PD between January 2013 and December 2020 and who were followed up for at least 1 year were included. Preoperative data, operative outcomes, and postoperative courses were compared between the BHS group and the group of patients who did not develop stenosis during follow-up (non-BHS group). The course of treatment in the BHS group was also examined. Results: BHS occurred in 13 of 175 patients (7.4%). Multivariate analysis of the BHS and non-BHS groups revealed that male sex (OR; 3.753, 95% CI; 1.029–18.003, P = 0.0448) and a preoperative bile duct diameter less than 8.8 mm (OR; 7.51, 95% CI; 1.75–52.40, P = 0.0053) were independent risk factors for the development of BHS. In the BHS group, all patients underwent ERC using enteroscopy. The success rate of the ERC approach to the bile duct was 92.3%. Plastic stents were inserted in 6 patients, and metallic stents were inserted in 3 patients. The median observation period since the last ERC was 17.9 months, and there was no recurrence of stenosis in any of the 13 patients. Conclusions: Patients with narrow bile ducts are at greater risk of BHS after PD. Recently, BHS after PD has been treated with ERC-related procedures, which may reduce the burden on patients. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effect of anesthesia with esketamine and propofol on postoperative pain and inflammatory markers in patients undergoing laparoscopic cholecystectomy (LC). Methods: Eighty-four patients who were scheduled to undergo LC in the hospital from December 2021 to December 2023 were selected, and divided into a control group and an observation group using the random number table method, with 42 cases in each group. The two groups were given anesthesia induction with propofol and sufentanil,and anesthesia induction with propofol and esketamine, respectively. Perioperative related indicators in the two groups were observed.Ramsay sedation scores of the two groups when the patients entered the room (T0), after anesthesia induction (T1), at 10 min after the beginning of surgery (T2), at the end of surgery (T3), and when they were awake (T4) were analyzed. The Visual Analogue Scale (VAS）scores of the two groups at 1 h, 6 h, 12 h and 24 h after surgery were evaluated. Stress response indicators before surgery and at 24 h after surgery, and changes in inflammatory markers before surgery and on day 1 and day 3 after surgery were compared between the two groups. The incidence rates of adverse reactions in the two groups were calculated. Results: Comparison between the observation group and the control group found that wake-up time and PACU stay of the former group were shorter. The total dosage of propofol in the former group was lower (P＜0.05). At T1 and T2, Ramsay sedation scores of the former group were higher. At T3, Ramsay sedation score of the former group was lower (P＜0.05). The levels of Cor, NE, and Glu in the former group were lower on day 1 after surgery (P＜0.05). The levels of CRP and IL-6 in the former group were lower on day 1 and day 3 after surgery (P＜0.05). The incidence rates of adverse reactions showed no significant difference between groups (P＞0.05). Conclusion: Anesthesia with esketamine and propofol can achieve good sedative effect on patients undergoing LC, which can reduce the dosage of anesthetics, promote postoperative recovery, inhibit inflammation and stress reaction, and alleviate postoperative pain. [ABSTRACT FROM AUTHOR]

Background: The biliary duct anastomosis performed during living donor liver transplantation (LDLT) surgery is a critical surgical procedure that significantly influences postoperative patient mortality and morbidity. The aim of the present study was to evaluate the feasibility of utilizing the recipient's cystic duct along with the common bile duct in situations where biliary duct anastomosis becomes necessary. Materials and Methods: In 16 of 49 liver transplants performed at Harran University Faculty of Medicine Organ Transplant Clinic between 2018 and 2021, the donor graft had double bile duct orifice. For the anastomosis of these bile ducts, the cystic duct was used along with the common bile duct in 9 patients, whereas in 7 patients, reconstruction was completed using various techniques without utilizing the cystic duct. Patients who underwent anastomosis to the cystic duct and those who underwent alternative techniques were evaluated in terms of difficulty and complications. Results: Of the 16 patients included in the study, 7 (44%) were female and 9 (56%) were male. The mean age was 51.18 (±12.77) years. Anastomosis was performed to the cystic duct in nine patients. Regarding postoperative complications, among patients who underwent anastomosis to the cystic duct, only one developed bile leakage, which was treated with endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous drainage. Complications developed in 3 of 7 patients in the other group. The two cases of bile duct strictures were treated with ERCP, while the bile leakage in one patient was conservatively monitored, and the leakage resolved spontaneously. Conclusion: The utilization of the cystic duct in bile duct anastomosis in LDLT may offer advantages, especially in grafts with multiple and distant bile ducts. When preparing donors for LDLT, when multiple bile ducts are detected in the donor liver preoperatively or intraoperatively, it should be kept in mind that in cases with a narrow donor pool, the cystic duct can also be used in the anastomosis. [ABSTRACT FROM AUTHOR]

Aim and objectives: The surgeon must recognize variations in the gallbladder, bile ducts, arteries that supply them, and liver to prevent unintentional ductal ligation, biliary leaks, and strictures after cholecystectomy. This study's objective was to investigate the structural changes that take place in the extrahepatic biliary tree and vasculature after cholecystectomy by comparing pre- and post-operative images. Materials and method: This Prospective Intraoperative observational study was conducted in the department of General Surgery, Santosh Medical College and Hospital from July 2021 to June 2022. The sample size was calculated to be 139 patients. Common Hepatic Duct formation, Right and left hepatic duct union, Types of cystic-hepatic duct union, Cystic duct and common hepatic duct, duct length, Hepato-duodenal ligament structures, Ductal variations, Arterial, duct, and Calot's triangle variations. Results: Majority (31.8%) belonged to 26-35 years followed by 36-45 years (29.1%), 46-55 years (18.9%), Above 55 years (10.8%) and 15-25 years (9.5%). There were 26.4% males and 73.6% females. Calot was frozen among 23.0% and Accessory artery in calot was found among 2.0% subjects. The anomalies were Aberrant right hepatic artery (0.7%), Accessory artery (1.4%), Double cystic duct (0.7%), Empyema (8.8%), Gb polyp (0.7%), Micro Gallbladder (0.7%), Mucocele (1.4%), Necrosed gall bladder (1.4%), Phregian cap (0.7%), Pyocele with moynihan hump (0.7%) and Type 2 bile duct injury (0.7%). Conclusion: Short cystic duct and intrahepatic gall bladder alterations are most common. Cholecystectomy discloses extrahepatic biliary problems. Every surgeon should watch for these variations to avoid unintended ductal cutting, ductal injuries, and haemorrhage during laparoscopic and open cholecystectomy. [ABSTRACT FROM AUTHOR]

Background: Extrahepatic manifestations in patients with primary biliary cholangitis (PBC) are frequently observed recently. We aimed in this study to explore the clinicopathological characteristics and prognosis of glomerulonephritis in patients with PBC. Methods: Consecutive PBC patients admitted to Peking Union Medical College Hospital from January 2002 to May 2019 were retrospectively enrolled. PBC patients with other autoimmune diseases which may have nephritis were excluded. Structured interview, systemic rheumatologic examination, and laboratory tests were conducted for each patient. Literature about patients with PBC and glomerulonephritis was reviewed and summarized. Results: Among the 330 PBC patients enrolled, glomerulonephritis were identified in 10 patients (3.0%). Eight (80.0%) were females and 2 (20.0%) were males. The mean age was 58.4 ± 9.5 years old. Membranous nephropathy (MN) was revealed in 4 patients, IgA nephropathy (IgA N) in 2 patients, minimal change disease (MCD) in 2 patients, mesangial proliferative glomerulonephritis in 1 patient, and renal amyloidosis in 1 patient. Compared to the literature reviewed, 10 cases of MN, 1 case of MCD, 1 case of IgA N, and 1 case of acute poststreptococcal glomerulonephritis (APSGN) were observed. Conclusions: Glomerulonephritis may not be a well-recognized feature of PBC and is not a rare complication and deserved to be routinely screened in clinical practice. As MN is the most common form of glomerulonephritis in PBC patients and PBC can be asymptomatic at an early stage, patients presented with MN should be screened for PBC, so to avoid cirrhosis. Key Points • Patients with primary biliary cholangitis (PBC) can be complicated with glomerulonephritis, and membranous nephropathy (MN) is the most common form. [ABSTRACT FROM AUTHOR]

There are no standard management protocols for the treatment of bile leak (BL) after liver transplantation. The objective of this study is to describe treatment options for BL after pediatric LT. Methods: Retrospective analysis (January 2010–March 2023). Variables studied: preoperative data, status at diagnosis, and postoperative outcome. Four groups: observation (n = 9), percutaneous transhepatic cholangiography (PTC, n = 38), ERCP (2), and surgery (n = 27). Results: Nine hundred and thirty‐one pediatric liver transplantation (859 LDLT and 72 DDT); 78 (8.3%) patients had BL, all in LDLT. The median (IQR) peritoneal bilirubin (PB) level and fluid‐to‐serum bilirubin ratio (FSBR) at diagnosis was 14.40 mg/dL (8.5–29), and 10.7 (4.1–23.7). Patients who required surgery for treatment underwent the procedure earlier, at a median of 14 days (IQR: 7–19) versus 22 days for PTC (IQR: 15–27, p = 0.002). PB and FSBR were significantly lower in the observation group. In 11 cases, conservative management had resolution of the BL in an average time of 35 days, and 38 patients underwent PTC in a median time of 22 days (15–27). Twenty‐seven (34.6%) patients were reoperated as initial treatment for BL in a median time of 17 days (1–108 days); 25 (33%) patients evolved with biliary stricture, 5 (18.5%) after surgery, and 20 (52.6%) after PTC (p = 0.01). Conclusion: Patients with BL who were observed presented significantly lower levels of PB and FSBR versus those who underwent PTC or surgery. Patients treated with PTC presented higher rates of biliary stricture during the follow‐up. [ABSTRACT FROM AUTHOR]

Background: The use of prophylactic drainage after laparoscopic cholecystectomy has been a routine practice for many years. However, the debate surrounding using it stems from conflicting evidence regarding its potential benefits and risks. Methods: Patients who underwent laparoscopic cholecystectomy from February 1, 2022, to November 30, 2022, at Aleppo University Hospital were enrolled according to our previously registered protocol (NCT05267860). Results: This study included 232 patients (117 in the drainage group [DG], and 115 in the non‐drainage group [NDG]). There was no statistical difference in the patients' main characteristics, comorbidities, and laboratory findings. The duration of the surgical operation in NDG (mean = 44.92, SD = 1.85) was shorter than in DG (mean 55.14, SD = 2.14), with (p = 0.039) statistically significant, which indicates that the use of the drainage led to a prolongation of the surgical operation. The total number of complicated cases reached 22 (9.48%) cases (DG = 9 vs. NDG = 13, p = 0.348) as follows: bleeding (n = 1) (DG = 1 vs. NDG = 0; p = 0.320), bile leak with no established bile duct injury (n = 1) (DG = 1 vs. NDG = 0; p = 0.320), wound infection (n = 12) (DG = 4 vs. NDG = 8; p = 0.443), urinary tract infection (n = 3) (DG = 0 vs. NDG = 3; p = 0.079), prolonged shoulder pain (n = 2) (DG = 0 vs. NDG = 2; p = 0.152), and acute pancreatitis (n = 1) (DG = 1 vs. NDG = 0; p = 0.144). Conclusion: Based on the results of our study, the use of prophylactic drainage was safe, but ineffective, as it did not improve the outcomes statistically significantly or worsen them, which is consistent with previous studies highlighting the need for personalized patient care in this setting. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to present the institutional experience and algorithm for performing biliary interventions in liver transplant patients using the modified Hutson loop access (MHLA) and the impact of percutaneous endoscopy via the MHLA on these procedures. Methods: Over 13 years, 201 MHLA procedures were attempted on 52 patients (45 liver transplants; 24 living and 21 deceased donors) for diagnostic (e.g., cholangiography) and therapeutic (e.g., stent/drain insertion and cholangioplasty) purposes. The most common indications for MHLA were biliary strictures (60%) and bile leaks (23%). Percutaneous endoscopy was used to directly visualize the biliary-enteric anastomosis, diagnose pathology (e.g., ischemic cholangiopathy), and help in biliary hygiene (removing debris/casts/stones/stents) in 138/201 (69%) procedures. Technical success was defined as cannulating the biliary-enteric anastomosis and performing diagnostic/therapeutic procedure via the MHLA. Results: The technical success rate was 95% (190/201). The failure rate among procedures performed with and without endoscopy was 2% (3/138) versus 13% (8/63) (P = 0.0024), and the need for new transhepatic access (to aid the procedure) was 12% (16/138) versus 30% (19/63) (P = 0.001). Despite endoscopy, failure in 2% of the cases resulted from inflamed/friable anastomosis (1/3) and high-grade stricture (2/3) obstructing retrograde cannulation of biliary-enteric anastomosis. Major adverse events (bowel perforation and injury) occurred in 1% of the procedures, with no procedure-related mortality. Conclusions: MHLA-based percutaneous biliary intervention is a safe and effective alternative to managing complications after liver transplant. Percutaneous endoscopy via the MHLA improves success rates and may reduce the need for new transhepatic access. Level of Evidence Level 4 [ABSTRACT FROM AUTHOR]

Simple Summary: Post-pancreaticoduodenectomy complications are still a major concern nowadays, and we focused on one of the most catastrophic conditions observed from clinical practice, the postoperative biliary infection, which may cause postoperative intensive care unit admission or mortality. Evaluating the impact on postoperative biliary tract infection from endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography and drainage before surgery is important to clinical circumstances. Biliary pathogens identified with a positive yield of intra-operative bile culture in patients undergoing pancreaticoduodenectomy were also investigated. The result showed that performing endoscopic retrograde cholangiopancreatography enhances the likelihood of achieving a positive yield from intraoperative biliary culture. Thus, PTCD emerges as a potentially favorable option for patients with obstructive jaundice and is indicated for pancreaticoduodenectomy. Background: For patients with obstructive jaundice and who are indicated for pancreaticoduodenectomy (PD) or biliary intervention, either endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography and drainage (PTCD) may be indicated preoperatively. However, the possibility of procedure-related postoperative biliary tract infection (BTI) should be a concern. We tried to evaluate the impact of ERCP and PTCD on postoperative BTI. Methods: Patients diagnosed from June 2013 to March 2022 with periampullary lesions and with PD indicated were enrolled in this cohort. Patients without intraoperative bile culture and non-neoplastic lesions were excluded. Clinical information, including demographic and laboratory data, pathologic diagnosis, results of microbiologic tests, and relevant infectious outcomes, was extracted from medical records for analysis. Results: One-hundred-and-sixty-four patients from the cohort (164/689) underwent preoperative biliary intervention, either ERCP (n = 125) or PTCD (n = 39). The positive yield of intraoperative biliary culture was significantly higher in patients who underwent ERCP than in PTCD (90.4% vs. 41.0%, p < 0.001). Although there was no significance, a trend of higher postoperative BTI (13.8% vs. 2.7%) and BTI-related septic shock (5 vs. 0, 4.0% vs. 0%) in the ERCP group was noticed. While the risk factors for postoperative BTI have not been confirmed, a trend suggesting a higher incidence of BTI associated with ERCP procedures was observed, with a borderline p-value (p = 0.05, regarding ERCP biopsy). Conclusions: ERCP in patients undergoing PD increases the positive yield of intraoperative biliary culture. PTCD may be the favorable option if preoperative biliary intervention is indicated. [ABSTRACT FROM AUTHOR]

Objective: Rare disease Background: Gallbladder anomalies are rare congenital defects with an incidence rate of approximately 2% in the general population. Phrygian cap gallbladder is a common anatomical variant in which the fundus of the gallbladder folds on itself. Gallstone impaction is rare, and it can be associated with acute pancreatitis. This report describes a 42-year-old woman with recurrent pancreatitis associated with gallstones and Phrygian cap gallbladder. Case Report: We report the case of a 42-year-old woman with acute biliary pancreatitis and a history of repeated hospitalizations for episodes of pancreatitis. A preoperative MRI was conducted, which revealed the presence of a Phrygian cap gallbladder that had not been previously reported in imaging studies. The patient underwent cholecystectomy surgery with a laparo-endoscopic approach (rendezvous technique). No intra-or postoperative complications occurred. Conclusions: We report a case of acute biliary pancreatitis caused by stone migration and describe the anatomical variant of the Phrygian cap gallbladder with its clinical implications. The literature contains very few reports of cholecystitis or pancreatitis in patients with a gallbladder anomaly. Continuous reporting of anatomical variations of the gallbladder and biliary tract improves clinical knowledge, and knowledge of gallbladder anomalies is crucial to avoid injury to the biliary tract during laparoscopic cholecystectomy. This case emphasizes the importance of accurate preoperative evaluation to prevent serious surgical complications. [ABSTRACT FROM AUTHOR]

Purpose: The prognostic factors of subsequent liver transplantation (LT) in patients with biliary atresia (BA) who presented with jaundice-free native liver survival were investigated. Methods: This study retrospectively reviewed patients who underwent portoenterostomy (PE) for BA. Patients with jaundice-free native liver survival at 1 year postoperatively were divided into the autologous liver survivor and liver transplant recipient groups. Peri- and postoperative data were compared between the two groups. Results: Among 97 patients with BA, 29 who received LT within 1 year after PE were excluded from the analysis. Further, 48 patients currently living with native liver and 20 who received LT after 1 year postoperatively were compared. Bile lake (BL) was the strongest risk factor of LT. The risk score was 2.38 ∗ B L s c o r e + 0.00466 ∗ T B A , and the area under the receiver operating characteristic curve was 0.83. Patients with BL and those without significantly differed in terms of the native liver survival rate. Patients with BL who presented with not only cholangitis but also gastrointestinal hemorrhage and hepatopulmonary syndrome received LT. Conclusion: BL can cause different pathologies. Moreover, it is an evident risk factor of subsequent LT in patients with BA who are living with native liver at 1 year after PE. [ABSTRACT FROM AUTHOR]

Introduction: In acute obstructive common bile duct (CBD) stones endoscopic retrograde cholangiography for CBD stone removal before cholecystectomy (ChE) ('ERC-first') is the gold standard of treatment. Intraoperative antegrade balloon dilatation of the duodenal papilla during ChE with flushing of CBD stones to the duodenum ('ABD-during-ChE') may be an alternative 'one-stop-shop' treatment option. However, a comparison of outcomes of the 'ABD-during-ChE' technique and the'ERC-first' approach has never been performed. Methods: Retrospective case control matched study of patients suffering from obstructive CBD stones (< 8 mm) without severe pancreatitis or cholangitis that underwent the traditional 'ERC-first' approach versus the 'ABD-during-ChE' technique. Primary endpoint was the overall Comprehensive Complication Index (CCI®) from diagnosis to complete CBD stone removal and performed ChE. Results: A total of 70 patients were included (35 patients each in the 'ERC first'- and 'ABD-during-ChE'-group). There were no statistical significant differences in terms of demographics and disease specific characteristics between the two study groups. However, there was a not significant difference towards an increased overall CCI® in the 'ERC-first' group versus the 'ABD-during-ChE' group (14.4 ± 15.4 versus 9.8 ± 11.1, p = 0.225). Of note, six major complications (Clavien-Dindo classification ≥ IIIa) occurred in the 'ERC-first' group versus two in the 'ABD-during-ChE' group (17% versus 6%, p = 0.136). In addition, significantly more interventions and a longer overall time from diagnosis to complete clearance of bile ducts and performed ChE was found, when comparing the 'ERC-first' group and the 'ABD-during-ChE' group (3.7 ± 0.8 versus 1.1 ± 0.4, p < 0.001; 160.5 ± 228.6 days versus 12.0 ± 18.0 days, p < 0.001). Conclusion: In patients suffering from acute obstructive CBD stones smaller than 8 mm, compared to the 'ERC-first' approach, the 'ABD-during-ChE' technique resulted in significantly less interventions and reduced overall treatment time from diagnosis to complete clearance of bile ducts and performed ChE. This comes together with a strong trend of less intervention related complications in the 'ABD-during-ChE' group. [ABSTRACT FROM AUTHOR]

Introduction: Stump cholecystitis is managed by performing a completion cholecystectomy, which can be done either laparoscopically or by an open method. The use of indocyanine green (ICG) is known to improve the identification of the biliary tree anatomy, facilitating Calot’s triangle dissection and shortening surgery, thereby reducing the risk of bile duct injuries and making laparoscopic cholecystectomy safer. Patients and Methods: A retrospective analysis was performed of prospectively collected data from 15 patients at our institution from March 2016 to March 2021. Magnetic resonance cholangiopancreatography was performed in all 15 cases, showing remnant gall bladder in all cases with calculi within. Four cases had a dilated common bile duct (CBD) with CBD calculi. Endoscopic retrograde cholangiopancreatography (ERCP) and stone removal followed by CBD stenting were performed in the four patients with CBD calculi. These four cases were scheduled for surgery 4 weeks post‑ERCP. All 15 patients underwent laparoscopic completion cholecystectomy. The mean operating time was 80 min. Results: The post-operative period of all cases was uneventful, and the patients were discharged on post‑operative day 2 or day 3. All patients remained asymptomatic during 1–5 years of follow‑up. Conclusion: Laparoscopic completion cholecystectomy was performed safely in cases of stump cholecystitis and resulted in symptom relief during short-term follow-up. The use of ICG and near-infrared imaging in such cases helps identify the biliary anatomy, may contribute to the safety of laparoscopic completion cholecystectomy and might reduce the duration of surgery. [ABSTRACT FROM AUTHOR]

A proportion of patients who undergo intraoperative cholangiogram (IOC) do not have bile duct stones at the time of endoscopic retrograde cholangiopancreatography (ERCP), either due to the spontaneous passage of stones or a false-positive IOC. Glucagon has been utilized as an inexpensive tool to allow the passage of micro-choledocholithiasis to the duodenum and resolve filling defects caused by stones or air bubbles. The purpose of our study is to understand the change in diagnostic accuracy of IOC to detect choledocholithiasis with intraoperative glucagon. We conducted a retrospective study at a tertiary care center on adult patients who underwent laparoscopic cholecystectomy with IOC. The diagnostic accuracy of IOC was assessed before and after the administration of intravenous glucagon. Of 1455 patients, 374 (25.7%) received intraoperative glucagon, and 103 of these 374 patients (27.5%) showed resolution of the filling defect with the passage of contrast to the duodenum. Pre- and post-glucagon administration comparison showed enhancement in specificity from 78% to 83%, an increase in positive predictive value from 67.3% to 72.4%, and an improvement in the diagnostic accuracy of IOC from 81.5% to 84.3%. Our findings suggest that intraoperative glucagon administration carries the potential to reduce the rate of false-positive IOCs, thereby reducing the performance of unnecessary ERCPs. [ABSTRACT FROM AUTHOR]

Background: Transarterial chemoembolization (TACE) is the standard treatment for intermediate‐stage hepatocellular carcinoma (HCC). Given the lack of specific recommendations for conventional TACE (cTACE) and drug‐eluting bead TACE (DEB‐TACE) in patients having unresectable HCC with tumor infiltrating the common hepatic duct or the first‐order branch of the bile ducts (B1‐type bile duct invasion; B1‐BDI) after biliary drainage, we retrospectively compared the safety and efficacy of DEB‐TACE with cTACE in this patient population. Materials and Methods: Using data from five tertiary medical centers (January 2017–December 2021), we compared complications, overall survival (OS), time to progression (TTP), and tumor response rate between patients having unresectable HCC with B1‐BDI who underwent DEB‐TACE or cTACE after successful biliary drainage. X‐tile software calculated the pre‐TACE total bilirubin (TBil) cutoff value, indicating optimal timing for sequential TACE after drainage. Propensity score matching (PSM) was performed. Results: The study included 108 patients with unresectable HCC (B1‐BDI) who underwent DEB‐TACE and 114 who received cTACE as initial treatment. After PSM (n = 53 for each group), the DEB‐TACE group had a longer TTP (8.9 vs. 6.7 months, p = 0.038) and higher objective response rate (64.2% vs. 39.6%, p = 0.011) than did the cTACE group, although OS was comparable (16.7 vs. 15.3 months, p = 0.115). The DEB‐TACE group exhibited fewer post‐procedural increments in the mean albumin‐bilirubin score, TBil, and alanine aminotransferase (ALT), along with a significantly lower incidence of serious adverse events within 30 days (hepatic failure, ALT increase, and TBil increase) than the cTACE group (all p < 0.05). The pre‐TACE TBil cutoff value was 99 μmol/L; patients with higher values (>99 μmol/L) had poorer OS in both groups (p < 0.05). Conclusion: DEB‐TACE is safe and effective after successful biliary drainage in unresectable HCC with B1‐BDI, potentially better than cTACE in terms of liver toxicity, TTP, and ORR. Lowering TBil below 99 μmol/L through successful drainage may create ideal conditions for sequential TACE. [ABSTRACT FROM AUTHOR]

Laparoscopic cholecystectomy is among the most common surgeries in adults and is increasing in the pediatric age group. However, data are lacking on complications of the surgery and their treatment in children. Although many case series can be found that address hepatic artery injury after cholecystectomy in adults, we could not find similar publications in the English literature relating to the pediatric age group. This report shares the complex diagnosis and treatment process of a six-year-old female patient who presented with jaundice eight months after laparoscopic cholecystectomy. During the treatment process, it was observed that the common bile duct went into lysis in the late period due to haptic artery injury. The treatment continued with redo hepaticojejunostomy and catheters passed through the anastomosis line in the patient, who had anastomotic stenosis after hepaticojejunostomy. Twenty-four months after the patient's first operation, she had no active complaints. Complications may occur months after a cholecystectomy. In this case, arterial injury should be kept in mind. We wanted to contribute by presenting the first case in the literature on hepatic artery injury in the pediatric age group. [ABSTRACT FROM AUTHOR]

The editorial in European Radiology discusses advancements in biliary stone management, focusing on percutaneous transhepatic endoscopic holmium laser lithotripsy for treating cholangiolithiasis and choledocholithiasis. The article highlights the evolution of percutaneous biliary interventions from fluoroscopy-based techniques to advanced endoscopic procedures, emphasizing the precision and efficacy of these treatments. A retrospective study by Nguyen Thai Binh and colleagues demonstrates the high success rate of percutaneous transhepatic endoscopic holmium laser lithotripsy in clearing biliary stones, offering a safe and effective alternative to traditional surgical methods. The study suggests that percutaneous approaches may be preferable in cases where endoscopic retrograde cholangiopancreatography is not feasible, showcasing the potential of these advanced biliary treatments in improving patient outcomes. [Extracted from the article]

Abstract Objective To study the predictive factors of false negatives in the diagnosis of biliary stricture (BS) by percutaneous transluminal clamp biopsy (PTCB). Method From January 2016 to January 2021, 194 patients with a high suspicion of malignant tumors due to BS underwent PTCB during biliary drainage at our department. The final diagnosis was confirmed by postoperative pathology, other tissue or cell evidence, or medical imaging follow-up. Univariate and multivariate regression analyses were performed on the pathological results, summarizing the independent risk factors for false-negative value (FNV) to help further clinical diagnosis and treatment. Results Of the 194 cases, 176 and 18 cases were finally diagnosed as malignant and benign BS, respectively, compared to 144 and 50 cases by PTCB, including 32 false-negative cases. The sensitivity, specificity, false-positive value, and FNV of PTCB were 81.8%, 100%, 0%, and 18.2%, respectively. Multivariate analysis showed that non-cholangiocarcinoma BS was an independent risk factor for FNV of PTCB (odds ratio 7.5 (95% CI 1.74–32.6), p

Introduction: Obstructive jaundice in neonates results from disruption of bile drainage from the liver, which may be related to several conditions. Differentiating between these conditions and intervening rapidly is critical, as the success of treatment for biliary atresia decreases as the infant ages. Case presentation: A 10-week-old term female born at 39 weeks of gestation was brought to the gastroenterology service to assess persistent jaundice. The jaundice was first noted by the patient's mother and pediatrician at 2 weeks of age and was thought to be physiologic. The stool during this period was reported to be normal in color. Laboratory investigations revealed obstructive jaundice (total bilirubin of 9.6 mg/dL; direct bilirubin of 5.6 mg/dL). Imaging demonstrated a cystic dilation of the common bile duct, concurrent dilation of the right hepatic duct, and no visible gallbladder. Given the ultrasound findings and parental report of normally colored stools, the diagnosis of an obstructed choledochal cyst was favored. However, due to the absence of a gallbladder, we obtained a magnetic cholangiography. The findings were similar, and with a presumed diagnosis of a type IV choledochal cyst the patient was taken to the operating room at the age of 91 days. A cystic dilatation of the common bile duct was found, with no distal duct. The structure identified as the right hepatic duct on imaging was found to be an atretic gallbladder. An intraoperative cholangiogram confirmed the diagnosis of cystic biliary atresia, and a Kasai portoenterostomy with Roux-en-Y reconstruction was performed. Postoperatively the hyperbilirubinemia resolved, but her liver function has gradually deteriorated, and she has been referred for a liver transplant. Conclusion: Biliary atresia can present with symptoms and imaging findings that mimic choledochal cysts. Given that the treatment and prognosis of these conditions vary, persistent neonatal jaundice must be worked up expeditiously, and a high index of suspicion for biliary atresia must be maintained.