Search

Background: International consensus on the ideal outcome for treatment of uncomplicated symptomatic gallstone disease is absent. This mixed-method study defined a Textbook Outcome (TO) for this large group of patients. Methods: First, expert meetings were organised with stakeholders to design the survey and identify possible outcomes. To reach consensus, results from expert meetings were converted in a survey for clinicians and for patients. During the final expert meeting, clinicians and patients discussed survey outcomes and a definitive TO was formulated. Subsequently, TO-rate and hospital variation were analysed in Dutch hospital data from patients with uncomplicated gallstone disease. Results: First expert meetings returned 32 outcomes. Outcomes were distributed in a survey among 830 clinicians from 81 countries and 645 Dutch patients. Consensus-based TO was defined as no more biliary colic, no biliary and surgical complications, and the absence or reduction of abdominal pain. Analysis of individual patient data showed that TO was achieved in 64.2% (1002/1561). Adjusted-TO rates showed modest variation between hospitals (56.6-74.9%). Conclusion: TO for treatment of uncomplicated gallstone disease was defined as no more biliary colic, no biliary and surgical complications, and absence or reduction of abdominal pain.TO may optimise consistent outcome reporting in care and guidelines for treating uncomplicated gallstone disease.

Tuberculosis continues to be a global disease. Abdominal tuberculosis is a not uncommon form of extrapulmonary tuberculosis and includes involvement of the gastrointestinal tract, peritoneum, lymph nodes, and solid organs. Its clinical picture depends on the site of involvement and the type of pathology. Abdominal tuberculosis can mimic several other diseases. Radiology and endoscopy play an important role in the diagnosis of abdominal tuberculosis and the polymerase chain reaction (PCR) -based XpertR test provides rapid results for confirmation. Treatment is with antitubercular therapy; complications, for example perforation and obstruction may require surgical intervention. Surgical procedures for abdominal tuberculosis are conservative. The mortality of abdominal tuberculosis, especially with acute presentation, remains high.

Mucinous cystic neoplasms (MCN) are mucin-producing epithelial cell tumors of pancreas. They consist of an ovarian-type stroma expressing estrogen and progesterone receptors. Pregnancy-associated MCNs are presumed to be larger in size and more aggressive without any concrete evidence.and Data Sources: Systematic review of published literature using PubMed and Google Scholar databases. Original articles including case reports and series published between 19702021 were included wherein MCN was diagnosed during pregnancy/within one-year post-partum. Thirty-three publications having 36 cases, adding one of our own patient were analyzed in this review.Median age at presentation was 32 years. Only three (9%) patients were asymptomatic. Mean size of MCN was 135 mm. Ten patients (27%) reported an increase in size during pregnancy. Most tumors involved body and tail of pancreas (60%). Distal pancreatectomy with splenectomy was the most common resection performed (57%). No foetal mortality was reported to date.Pregnancy may cause a rapid increase in size of MCN. Decision-making is more complex and needs a fine balance between optimal oncological and obstetric outcomes.

Gallbladder cancer (GBC) is the most common cancer of the biliary tract, characterized by a very poor prognosis when diagnosed at advanced stages owing to its aggressive behaviour and limited therapeutic options. Early detection at a curable stage remains challenging because patients rarely exhibit symptoms; indeed, most GBCs are discovered incidentally following cholecystectomy for symptomatic gallbladder stones. Long-standing chronic inflammation is an important driver of GBC, regardless of the lithiasic or non-lithiasic origin. Advances in omics technologies have provided a deeper understanding of GBC pathogenesis, uncovering mechanisms associated with inflammation-driven tumour initiation and progression. Surgical resection is the only treatment with curative intent for GBC but very few cases are suitable for resection and most adjuvant therapy has a very low response rate. Several unmet clinical needs require to be addressed to improve GBC management, including discovery and validation of reliable biomarkers for screening, therapy selection and prognosis. Standardization of preneoplastic and neoplastic lesion nomenclature, as well as surgical specimen processing and sampling, now provides reproducible and comparable research data that provide a basis for identifying and implementing early detection strategies and improving drug discovery. Advances in the understanding of next-generation sequencing, multidisciplinary care for GBC, neoadjuvant and adjuvant strategies, and novel systemic therapies including chemotherapy and immunotherapies are gradually changing the treatment paradigm and prognosis of this recalcitrant cancer.

Biliary injury is the most feared complication of laparoscopic cholecystectomy (LC). This study aimed to assess the awareness of culture of safety in cholecystectomy (COSIC) concept among the surgical residents in India. A manual survey was conducted among general surgery residents attending a postgraduate course. Survey consisted of questions pertaining to knowledge of various aspects of COSIC, e.g., the critical view of safety (CVS). With a response rate of 51%, 259 residents were included in this study. They had more exposure to LC (63.3% assisted / performed > 15 LC) than to open cholecystectomy (60.6% assisted / performed ≤ 10 open cholecystectomy). The majority (80.2%) clearly differentiated Calot triangle from the hepatocystic triangle (HCT). However, 25.8% could not correctly define HCT. The majority (88.5%) had seen the Rouviere’s sulcus during LC. While almost all (98.4%) respondents claimed to know about the segment 4, only 41.9% could correctly describe it. Awareness of the correct direction of the gallbladder retraction was lower for the infundibulum (53.5%) than for fundus (89.2%). The majority (88.3%) claimed to know CVS but only 11.5% knew it correctly, and 15.1% described > 3 components. The majority (78.7%) practiced to identify the cystic duct-common bile duct junction. Awareness was low for time-out (28.1%), intraoperative cholangiography (20.6%), bailout techniques (18.9%), and for overall COSIC concept (15.7%). Knowledge of COSIC among surgical residents seems to be suboptimal, especially for the CVS, time-out, bailout techniques, and overall concept of COSIC. Strategies to educate them more effectively about COSIC are highly imperative to train them well for future practice.

Backgrounds/aims In the absence of national registry of laparoscopic cholecystectomy (LC) or its complications, it is impossible to determine incidence of bile duct injury (BDI) in India. We conducted an e-survey among practicing surgeons to determine prevalence and management patterns of BDI in India. Our hypothesis was that majority of surgeons would have experienced a BDI during LC despite large experience and that most surgeons who have a BDI tend to manage it themselves. Methods An 18-question e-survey of practicing laparoscopic surgeons in India was done. Results 278/727 (38%) surgeons responded. 240/278 (86%) respondents admitted to a BDI during LC and 179/230 (78%) affirmed to more than one BDI. A total of 728 BDIs were reported. 36/230 (15%) respondents experienced their first BDI even after ＞10 years of practice and 40% had their first BDI even after having performed ＞100 LCs. 161/201 (80%) of the respondents decided to manage the BDI themselves, including 56/99 (57%) non-biliary surgeons and 44/82 (54%) surgeons working in non-biliary center. 37/201 (18%) respondents admitted to having a mortality arising out of a BDI; the mortality rate of BDI was 37/728 (5%) in this survey. Only 13/201 (6%) respondents have experienced a medico-legal case related to a BDI during LC. Conclusions Prevalence of BDI is high in India and occurs despite adequate experience and volume. Even inexperienced non-biliary surgeons working in non-biliary centers attempt to repair the BDI themselves. BDI is associated with significant mortality but litigation rates are fortunately low in India.

Cholecystectomy is one of the commonest general surgical procedures performed all over India. The risk of bile duct injury (BDI) during laparoscopic cholecystectomy is two to three times higher than during open cholecystectomy. The worldwide incidence of bile duct injury is 0.5% or 1 in 200 cases. BDI and its consequences result in significant morbidity and may even cause mortality. BDI increases the cost of treatment and is a common reason for a medicolegal suit against the surgeons. To minimize the incidence of BDI and to manage it timely and appropriately, a set of guidelines was deemed necessary by a group of senior surgeons during a Society of Endoscopic and Laparoscopic Surgeons of India (SELSI) meeting in 2016. Guidelines for “Safe Laparoscopic Cholecystectomy” and bile duct injury management formulated by other international societies are already available. The applicability of these guidelines to Indian subjects especially in small peripheral centers was limited. Hence, a decision was taken to form a set of guidelines for general surgeons with basic laparoscopic skills with little or no advanced laparoscopic skills. Those working in a solo practice, nursing homes, and small private hospitals at talukas or districts should have “Safe Cholecystectomy” guidelines and management of BDI suitable to their situation. These guidelines were formed after three consensus meetings and have been approved by a SELSI Expert Group.

Background:Plant sterols have proven a potent anti-proliferative and apoptosis inducing agent against several carcinomas including breast and prostate cancers. Jab1 has been reported to be involved in the progression of numerous carcinomas. However, antiproliferative effects of sterols against Jab1 in gall bladder cancer have not been explored yet.Objective:In the current study, we elucidated the mechanism of action of stigmasterol regarding apoptosis induction mediated via downregulation of Jab1 protein in human gall bladder cancer cells.Methods:In our study, we performed MTT and Trypan blue assay to assess the effect of stigmasterol on cell proliferation. In addition, RT-PCR and western blotting were performed to identify the effect of stigmasterol on Jab1 and p27 expression in human gall bladder cancer cells. We further performed cell cycle, Caspase-3, Hoechst and FITC-Annexin V analysis, to confirm the apoptosis induction in stigmasterol treated human gall bladder cancer cells.Results:Our results clearly indicated that stigmasterol has up-regulated the p27 expression and down-regulated Jab1 gene. These modulations of genes might occur via mitochondrial apoptosis signaling pathway. Caspase-3 gets activated with the apoptotic induction. Increase in apoptotic cells and DNA were confirmed through annexin V staining, Hoechst staining, and cell cycle analysis.Conclusion:Thus, these results strongly suggest that stigmasterol has the potential to be considered as an anticancerous therapeutic agent against Jab1 in gall bladder cancer.

Background Proximal splenorenal shunt (PSRS) is one of the most commonly performed portosystemic shunt (PSS) in extrahepatic portal venous obstruction (EHPVO) for portal decompression. Sometimes various anatomical and surgical factors related to the splenic vein and/or left renal vein may make the construction of a PSRS difficult or impossible. Unconventional shunts are required to tide over such conditions. Methods From January 2008 to December 2018, 189 patients with EHPVO underwent PSS, of which, the 10 patients who underwent unconventional shunts form the study group of this paper. Results The ten unconventional shunts included 8 proximal splenoadrenal shunts, one collateral-renal shunt, and one inferior mesenteric vein to inferior vena cava (IMV-Caval) shunt. The mean percentage drop in omental pressure was 34.2% post-shunt with a mean anastomotic diameter of 13.7 ± 3.1 mm. Three patients experienced some form of postoperative complication. With a mean follow-up period of 32.3 months (maximum of 111 months) all patients had patent shunts on follow-up Doppler. None of the patients had variceal bleed, or features of biliopathy and hepatic encephalopathy in follow-up. Conclusion Unconventional shunts can be used safely and effectively with good postoperative outcomes in EHPVO.

PurposeGallbladder cancer (GBC) is most aggressive malignancy having very short survival having heterogeneous incidence, clinical and molecular profile. We evaluated molecular targets and mismatch-repair (MMR) protein expression in North-Indian patients. Method111 cases were subjected to high-resolution melt curve, followed by Sanger sequencing for KRAS, BRAF and PIK3CA. Immunohistochemistry was done for four MMR proteins. ResultsSix (5.4%) cases showed KRAS mutation while no mutation was found in BRAF and PIK3CA. Deficient MMR was seen in 27.6% of GBC. All KRAS mutant cases were >50 years having higher perineural invasion (67%), lymphnode metastasis (67%) and stage-III disease (67%). MMR deficient GBC were significantly associated with well differentiated histology. KRAS mutant GBC had shorter mean survival than wild patients. MMR deficient GBC showed longer mean survival than MMR proficient cases. 10% of MMR deficient compared to 4% MMR proficient GBC showed KRAS mutation. ConclusionKRAS mutation was lower in North Indian patients despite having high GBC incidence making these patients suitable for targeted therapy. It was associated with poor prognostic factors and lower mean survival. MMR deficiency was higher and harbored predominantly well-differentiated histology with higher mean survival. Molecular targets and MMR expression in GBC may guide towards more appropriate approach in these patients.

Extended cholecystectomy includes removal of the gall bladder with a 2 cm non-anatomical wedge of the liver and lymphadenectomy. Some variations of extended cholecystectomy include anatomical segments IVB + V resection and common bile duct excision. Extended cholecystectomy can be performed laparoscopically in selected cases with early gall bladder cancer. Extended cholecystectomy can be curative for early gall bladder cancer (tumor confined to gall bladder wall and lymph nodes confined to the hepatoduodenal ligament).

Extended cholecystectomy is the standard surgical procedure for gall bladder cancer (GBC), but very few patients with a preoperative diagnosis of GBC are suitable for it. Many patients with advanced GBC need more major resections. GBC patients with jaundice need CBD excision along with extended cholecystectomy and often require a major hepatectomy in the form of extended right hepatectomy (ERH). These patients require extensive invasive preoperative preparation in the form of preoperative biliary drainage and portal vein embolization. Morbidity of major hepatectomy for GBC is high and mortality is significant. Hepato-pancreatoduodenectomy (HPD) for GBC is debatable and its role is being questioned. Combined resection of adjacent organs (CRAO), e.g., colon and duodenum, is very frequently required to achieve R0 resection. Vascular, hepatic artery and portal vein, resection is not recommended for GBC.

The gall bladder is intimately related to the liver, hepatoduodenal ligament containing the common bile duct, proper hepatic artery and main portal vein, duodenum—pancreas and colon resulting in early and frequent involvement of these structures in gall bladder cancer. Gall bladder straddles segments IV and V of the liver, parts of which are always removed during radical resection for gall bladder cancer. Lymphatic spread occurs to cystic, pericholedochal, and pancreato-duodenal lymph nodes; celiac, superior mesenteric, and aorto-caval are distant lymph nodes.

Patients who undergo surgical resection for gall bladder cancer should be followed with US, CT (and PET). Recurrences are common, occur early, and are usually distant as well as locoregional. T and N stage, histological features and resection status predict prognosis and survival. Better survival rates have been reported from centers in Japan. Overall, however, gall bladder cancer is a bad cancer per se.

Gallbladder cancer (GBC), though a rare cancer worldwide, is common in some geographical areas and some ethnic groups. It is common in central and south America (Chile), South Asia (northern India) and East Asia (Japan, Korea, and China), and in the Native American people. Gallstones are the most important risk factor for etiopathogenesis of GBC.

Great contributions have been made in the area of gallbladder cancer by Chile and Japan. In this chapter, the author recounts his interactions with these two countries.

Majority of patients with gall bladder cancer have locally advanced unresectable or metastatic disease and are beyond resection. They need palliation from pain, jaundice, and gastrointestinal obstruction. Palliation is, by and large, nonsurgical, i.e., endoscopic or percutaneous radiological; surgery is rarely required for palliation. Celiac plexus neurolysis may help control pain. Jaundice is taken care of by biliary drainage using stents. Endoscopic biliary drainage is preferred but percutaneous transhepatic biliary drainage may be required in high biliary obstruction. Gastroduodenal obstruction can be palliated by placement of stents but intestinal obstruction may need surgical intervention. Chemo and/or radiotherapy are being increasingly used in definitive palliative stetting.

Biliary tract obstruction causes jaundice, pruritus, and cholangitis. Patients with malignant obstructive jaundice suffer from malnutrition and may develop deficiencies of nutrients. The deficiency of vitamin K causes coagulopathy. Preoperative biliary drainage can reverse some of the pathophysiological effects of biliary obstruction. Endoscopic biliary drainage is preferred over percutaneous biliary drainage. Portal vein embolization can increase the functional liver remnant before a major hepatectomy.

Global Cancer Observatory of the International Agency for Research against Cancer (IARC) (gco.iarc.fr) is an interactive web-based platform presenting global cancer statistics using data from GLOBOCAN and Cancer Incidence in Five Continents (CI5) Vol XI.

Gall bladder cancer (GBC) can be clinically obvious or suspected on imaging; it may be an incidental finding on histopathology. Early GBC may be asymptomatic or its symptoms may resemble those of gall stone disease. Advanced GBC presents with pain and jaundice, and anorexia and weight loss; a gall bladder lump may be palpable. Unusual clinical presentations include acute cholecystitis, gastric outlet obstruction, and gastro-intestinal bleed. Metastases occur to liver and peritoneum; left supraclavicular lymph node and umbilicus are unusual sites of metastasis. Differential diagnosis of GBC includes gall stone disease, gall bladder perforation, Mirizzi syndrome, cholangiocarcinoma, and thick wall gall bladder.

American Joint Committee on Cancer (AJCC)—International Union Against Cancer (UICC) tumor node metastasis (TNM) staging system is most commonly followed for gall bladder cancer. Japanese surgeons frequently use the Japan Society of Biliary Surgery (JSBS) classification; lymph nodal staging is better in the JSBS classification. Frequent haphazard changes have been made in the staging of gall bladder cancer in various editions of the AJCC-UICC staging. The author (VKK) proposes some changes in the AJCC-UICC staging of gall bladder cancer to bring it in uniformity with other organs; inclusion of jaundice and the site of tumor in the gall bladder are also suggested.

Surgical resection is the mainstay of management of gall bladder cancer. Majority of patients, however, develop recurrences (usually distant) after surgical resection, thus emphasizing the role of adjuvant therapy (mainly chemotherapy), especially in high-risk cases. There is some evidence that chemoradiotherapy may be better than chemotherapy alone. Neoadjuvant therapy for borderline resectable gall bladder cancer is under evaluation. Molecular biology of gall bladder cancer is being studied to identify potential targets for biological therapy.

The philosophy of management of gall bladder cancer ranges from the Japanese aggressive approach (major supra-radical multi-organ resections for advanced disease) at one end to the western pessimistic nihilism (inappropriate management of even early disease) at the other. An Indian “Buddhist” middle path, i.e., aggressive surgical approach towards early (and incidental) gall bladder cancer and non-surgical palliation for advanced gall bladder cancer has been advocated by the author (VKK).

Treatment of gall bladder cancer is difficult; prevention is, therefore, important. Primary prevention is not an option as the etiology of gall bladder cancer is not known. Preventive cholecystectomy for asymptomatic gall stones offers secondary prevention but is not recommended as the anticipated costs (and complications) are high and the quantum of the expected benefits is not known. Patients with symptomatic gall stones should be advised to undergo early cholecystectomy (tertiary prevention). All gall bladders removed for gall stones should be subjected to histopathological examination to detect an incidental (early) gall bladder cancer (quaternary prevention).

Ultrasonography (US) is the first investigation in a patient with biliary symptoms; US detects advanced gall bladder cancer (GBC) but has poor sensitivity to diagnose early GBC. Suspicion of GBC on US mandates evaluation with computed tomography (CT). Magnetic resonance imaging (MRI) with magnetic resonance cholangiography (MRC) should be performed in patients with jaundice. Positron emission tomography (PET) is useful to detect distant metastases. Tissue diagnosis is not essential if the disease is potentially resectable. Staging laparoscopy to detect surface peritoneal deposits is strongly recommended before laparotomy. Invasive cholangiography—endoscopic retrograde cholangiography (ERC) or percutaneous transhepatic cholangiography (PTC)—should be performed only as a part of a therapeutic procedure for biliary drainage.

Gallstones are the most important risk factor for the causation of gallbladder cancer. Long-standing gallstone disease increases the risk of gallbladder cancer. Hormonal factors play a role as gallbladder cancer is more common in females than males. Diet, lifestyle, infections (Salmonella and Helicobacter), heavy metals, and pesticides have been incriminated. Inflammation—dysplasia pathway is more commonly involved than the adenoma—carcinoma pathway in pathogenesis. Molecular changes and signaling pathways involved in gallbladder cancer are being studied.

Background: Typhoid (Salmonella typhi and paratyphi) carriers and gall bladder cancer (GBC) are endemic in northern India. Results of previous studies about association of typhoid carriers with GBC are inconsistent. We studied antibodies against Salmonella typhi and paratyphi in serum samples of patients with GBC. Methods: We performed modified Widal test for antibodies against Salmonella typhi (Vi and O) and Salmonella paratyphi (AO and BO) antigens in patients with GBC (n=100), xanthogranulomatous cholecystitis (XGC, n=24), chronic cholecystitis (CC, n=200) and healthy controls (HC, n=200). Results: Serum antibodies against Salmonella were more frequently positive in GBC (22%) and XGC (29%), particularly in males in age ≥50 years (GBC: 47% and XGC: 50%) vs. HC (0) (P

Background: Carcinogen metabolism pathway and tumor suppressor gene polymorphisms have been reported to be associated with increased gallbladder cancer risk. However, the association of genetic variants and gallbladder cancer risk in Indians are not well studied. We examined whether genetic polymorphisms of metabolic enzymes cytochrome P450 1A1 and glutathione S-transferase and tumor suppressor gene p53 (TP53) are associated with an increased risk of gallbladder cancer in North Indians. Methods: This hospital-based case-control study was conducted in 96 gallbladder cancer patients with gallstones (cases) and 93 cholelithiasis patients (controls) at the Sanjay Gandhi Postgraduate Institute of Medical Sciences in Lucknow, India from July 2014 through May 2017. Genomic DNA was extracted from white blood cells of each patient using a simple salting-out procedure. The genotypic frequencies of CYP1A1 rs4646903, CYP1A1 rs1048943, and TP53 rs1042522 polymorphisms were investigated using TaqMan SNP Genotyping Assay and GSTM1 and GSTT1 polymorphisms were analyzed using the multiplex PCR assay. Results: The frequency of CC genotype of TP53 rs1042522 polymorphism was 27.1% (26/96) in cases and 12.9% (12/93) in controls. The CC genotype was associated with an increased risk of gallbladder cancer in North Indians (age- and sex-adjusted odds ratio, 2.81; 95% confidence interval, 1.19–6.61; P = 0.02). No significant differences in genotypic and allelic frequencies of the metabolic pathway gene polymorphisms were found between cases and controls. Conclusions: Our data provide preliminary evidence that the CC genotype of the TP53 rs1042522 polymorphism may be associated with an increased risk of gallbladder cancer in North Indians.

A young agriculture scientist had a biliary colic and was taken for an elective laparoscopic cholecystectomy. Calot’s triangle was found to be frozen so it was converted to open operation when the common bile duct was found to be transected. Immediate end to end repair was done. She started developing progressively increasing jaundice associated with pruritus. ERCP showed a complete cutoff. MRCP showed biliary stricture Bismuth type II. She was referred to us and was operated. Bismuth type II BBS was found and Roux-en-Y side to side hepatico-jejunostomy was done. On POD 5, she had UGI bleed and her hemoglobin fell to 6.0 g/dl. Emergency UGIE revealed a large clot in D2. Emergency relaparotomy was done. Anterior layer of JJ was opened and intra-operative enteroscopy was done through it. Small bowel, including the Roux loop and distal loops, was full of altered blood. There was no bleeding from the HJ site. No active bleeding site was discernible anywhere. Posterior layer of JJ was reinforced and anterior layer was redone. She remained stable and her hemoglobin improved. She was discharged with normal LFT. “Doctor, is this my last surgery?” she asked, when she came to my office to hand over a very girlie colorful note book in which she had written down her story in her pearly handwriting, as beautiful as she herself. I talked to her about her PhD thesis, her exams, and her future career but purposely evaded answering her question as I could not muster the courage to tell a lie and say a definite “yes.” We, at SGPGIMS, have heard more than 700 stories similar to hers—some more and some less painful than hers—in the last 25 years. Most of these could have been avoided or could have been less devastating if the operating surgeons had paid a little more attention while performing the cholecystectomy to make it safe.

Some institutions and several individuals with large experiences have made significant contributions to our knowledge about bile duct injury during cholecystectomy. The following is a select list of these contributions

Hepatico-jejunostomy is the procedure of choice for repair of a bile duct injury/benign biliary stricture. The best time to repair bile duct injury is delayed (at least 6 weeks after the injury). Generous incision, good retraction, mobilization of the liver, and lowering of the hilar plate help to identify the extrahepatic left hepatic duct which, along with the biliary ductal confluence, is anastomosed to a Roux-en-Y limb of jejunum. Single layer of interrupted sutures of fine long-acting absorbable suture is preferred. Anastomotic stents may be used in selective cases. Bleed and anastomotic leak are important postoperative complications; anastomotic stricture may occur in the long term.

Most bile duct injuries will occur in the hands of a general surgeon. The injuring surgeon should avoid the temptation to repair the bile duct injury as results of this repair are going to be poor; it is also associated with increased costs and an increased risk of litigation. The injuring surgeon should, after resuscitation and stabilization, refer the patient to a biliary center for further management. Established benign biliary stricture should be repaired by a biliary surgeon.

Bile duct injury at cholecystectomy causes a bile leak which then results in an external biliary fistula. It could be uncontrolled, i.e., with intraperitoneal bile leak and sepsis. After drainage of peritoneal bile, it becomes a controlled fistula. The external biliary fistula following a partial bile duct injury closes in majority of the cases—some of these patients will form a benign biliary stricture. The external biliary fistula following a complete bile duct injury is less likely to close, but all these patients will require repair of the bile duct injury/benign biliary stricture. A biloma may rupture into the duodenum/colon forming an internal (bilio-enteric) fistula. Bilio-pleural, bilio-bronchial, and bilio-venous are rare internal fistulae.

Bile duct injury is the commonest iatrogenic injury during laparoscopic cholecystectomy but, less commonly, other (non-biliary) injuries can also occur. These include trocar related injuries to the omentum, bowel, urinary bladder, and great vessels. The surgeon should look for these injuries immediately after the placement of the first trocar. Injuries to the duodenum and colon can also occur during cholecystectomy. Vascular injuries (hepatic artery and portal vein) are also commonly associated with bile duct injuries during laparoscopic cholecystectomy. These (vascular) injuries are more common in patients with high (proximal) bile duct injury. Immediate or early repair of the bile duct injury should not be done in presence of a vascular injury. These (vascular) injuries may remain asymptomatic and go undetected or they may result in liver necrosis, abscess, or bleeding (hemobilia, caused by a pseudoaneurysm) in the short term or liver parenchymal atrophy in the long term. Some patients with a high (proximal) bile duct injury and associated vascular injury may require hepatectomy.

Knowledge of anatomy is a prerequisite for any operation. Anatomy becomes even more important in cholecystectomy because of a high prevalence of aberrant biliary and vascular anatomy in and around the Calot’s triangle. Cystic lymph node, Hartmann’s pouch, Rouviere’s sulcus, base of the quadrate lobe, first part of the duodenum, hepato-duodenal ligament, and pulsations of the proper hepatic artery are useful landmarks during cholecystectomy. Aberrant bile ducts may get injured during cholecystectomy and cause bile leak in the postoperative period. Injury to aberrant vessels can cause bleeding during the operation attempts to control which may in turn cause a bile duct injury. Surgical anatomy of the liver and bile ducts is relevant for repair of a biliary stricture in the form of hepatico-jejunostomy.

Pancreas is embryologically an unique organ with foregut and midgut origins. Functionally endocrine and exocrine roles contribute to this uniqueness. Clinically it is considered a meeting place of both surgeons and physicians alike. Pancreas has perplexed mankind for centuries and this chapter summarizes the embryology, gross anatomy and common congenital malformations of human pancreas with clinical perspective.

Terms bile leak, external biliary fistula, and benign biliary stricture define events during the clinical course of a bile duct injury. An ideal classification of bile duct injury and benign biliary stricture still eludes us. Strasberg’s classification is most commonly used for bile duct injury while benign biliary strictures are usually classified according to the Bismuth classification.

Gallstones occur all over the world. Cholecystectomy is the treatment for symptomatic gallstone disease. It is one of the commonest surgical procedures performed by a general surgeon. Most cholecystectomies today are performed laparoscopically. Bile duct injury is an uncommon complication of cholecystectomy. The risk of a bile duct injury is more during laparoscopic cholecystectomy. Bile duct injury is a dangerous complication which can even prove to be fatal. It is also a complication for the surgeon in the form of a medico-legal suit. This chapter describes a few of the many tips and tricks for the safe conduct of a laparoscopic cholecystectomy.

Bile duct injury is an uncommon but dangerous complication of cholecystectomy. The incidence of bile duct injury used to be low (0.1–0.2%) during the open cholecystectomy era but has increased about 2–3 times (0.4–0.6%) after the introduction and near universal adoption of laparoscopic cholecystectomy. These incidence rates are highly underreported as prospective nationwide databases show even higher rates. It was hoped that the high incidence of bile duct injury will decrease after laparoscopic cholecystectomy is introduced in surgical training programs and once experience is gained with the procedure, but this concept of “learning curve” has proved to be a myth as the incidence rates continue to remain high even after three decades of introduction of laparoscopic cholecystectomy and bile duct injuries continue to occur in the hands of even experienced and high volume surgeons.

A patient who sustains a bile duct injury and/or has a bile leak after cholecystectomy can develop a benign biliary stricture during the follow-up. Repair of a bile duct injury/benign biliary stricture in the form of end-to-end repair or hepatico-jejunostomy can restricture during the follow-up. Most anastomotic strictures occur in the first 2 years but they can occur even up to 10 years, hence the need for long-term follow-up. Follow-up is clinical and with liver function tests (LFT), ultrasonography (US), and isotope hepato-biliary scintigraphy. Suspected anastomotic stricture is confirmed by magnetic resonance cholangiography (MRC). Treatment of choice for anastomotic stricture is non-surgical (endoscopic or percutaneous transhepatic balloon dilatation and stenting). If the previous repair was inadequate, reoperation may be performed to do a proper hepatico-jejunostomy. Repeat hepatico-jejunostomy is technically challenging and results are inferior to those of primary hepatico-jejunostomy. Some patients with recurrent benign biliary stricture may require hepatectomy. Patients with anastomotic stricture can develop and die of biliary complications during the follow-up.

Management of bile duct injury/benign biliary stricture should be done at a biliary center which has the facilities and expertise for diagnostic and therapeutic endoscopy and diagnostic and interventional radiology. Percutaneous radiological intervention, i.e., catheter drainage of biloma and percutaneous transhepatic biliary drainage, and endoscopic intervention, i.e., biliary stenting are invaluable in the management of an acute bile duct injury and bile leak. Treatment of choice for an established benign biliary stricture is surgical, i.e., hepatico-jejunostomy. In some cases, e.g., those who are at high risk for surgery, either because of comorbidities or because of secondary biliary cirrhosis and portal hypertension, the stricture can be managed nonsurgically (endoscopic or percutaneous). This is, however, possible only in patients with biliary ductal continuity. Non-surgical management of a benign biliary stricture includes balloon dilatation and stenting; the stents need to be exchanged every few months and have to remain in place for long (about 12 months). Percutaneous radiological intervention is, however, the treatment of choice for an anastomotic stricture after hepatico-jejunostomy.