Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

Common bile duct (CBD) injury during cholecystectomy is a significant source of patient morbidity, but its impact on survival is unclear.To demonstrate the relation between CBD injury and survival and to identify the factors associated with improved survival among Medicare beneficiaries.Retrospective study using Medicare National Claims History Part B data (January 1, 1992, through December 31, 1999) linked to death records and to the American Medical Association's (AMA's) Physician Masterfile. Records with a procedure code for cholecystectomy were reviewed and those with an additional procedure code for repair of the CBD within 365 days were defined as having a CBD injury.Survival after cholecystectomy, controlling for patient (sex, age, comorbidity index, disease severity) and surgeon (procedure year, case order, surgeon specialty) characteristics.Of the 1 570 361 patients identified as having had a cholecystectomy (62.9% women), 7911 patients (0.5%) had CBD injuries. The entire population had a mean (SD) age of 71.4 (10.2) years. Thirty-three percent of all patients died within the 9.2-year follow-up period (median survival, 5.6 years; interquartile range, 3.2-7.4 years), with 55.2% of patients without and 19.5% with a CBD injury remained alive. The adjusted hazard ratio (HR) for death during the follow-up period was significantly higher (2.79; 95% confidence interval [CI]; 2.71-2.88) for patients with a CBD injury than those without CBD injury. The hazard significantly increased with advancing age and comorbidities and decreased with the experience of the repairing surgeon. The adjusted hazard of death during the follow-up period was 11% greater (HR, 1.11; 95% CI, 1.02-1.20) if the repairing surgeon was the same as the injuring surgeon.The association between CBD injury during cholecystectomy and survival among Medicare beneficiaries is stronger than suggested by previous reports. Referring patients with CBD injuries to surgeons or institutions with greater experience in CBD repair may represent a system-level opportunity to improve outcome.

Cholecystectomy is a common procedure with a notable risk of iatrogenic bile duct injury. Understanding the factors contributing to bile duct injury and the effectiveness of preventative measures is crucial for improving surgical outcomes. This meta-analysis aimed to identify and synthesize high-quality evidence on risk factors and mitigating measures associated with bile duct injury after cholecystectomy.

Bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is not as common now as in the past, but it is still a very debilitating complication. Therefore, there is a very strong need for a method that lowers the number of complications during LC without any additional risks for the patient and the operating team. Laparoscopic ultrasound (LUS), which serves to delineate anatomy, appears to be a very effective and safe technique.The aim of this study was to explore the advantages of performing LUS during difficult LC.The study group consisted of 126 patients who underwent surgery between January 2014 and February 2016. All the patients had difficult intraoperative anatomical conditions due to chronic inflammation, previous upper abdominal surgery or biliary pancreatitis in the past. We used a Toshiba PEF-704 LA laparoscopic probe and the Toshiba NemioMX SSA-590A diagnostic ultrasound system (Toshiba Corp., Tokyo, Japan). Doppler sonography was used to differentiate between vascular and biliary structures.Laparoscopic ultrasound ensured a safe plane of dissection and no biliary or vascular complications were observed. Stent insertion into the common bile duct before the operation undoubtedly made the identification of anatomical structures easier. Conversion to an open procedure was deemed necessary in only 6 patients (4.8%).Laparoscopic ultrasound facilitates the successful performance of LCs. It can be used at any time during the operation; it is noninvasive; and there is no need to use X-rays or contrast dye, or to cannulate the cystic duct. The most important advantage of LUS is that it leads to a lower number of conversions and intraoperative complications by identifying anatomical relationships in the plane of dissection.

As one of the most commonly performed surgeries in the world, safety during laparoscopic cholecystectomy (LC) is of utmost importance. Indocyanine green (ICG) has been used for different medical purposes including assessment of liver function since the 1950s. Its use during LC was first described in 2009 by Ishizawa. Since ICG is excreted in the bile, its fluorescent properties can be used to illuminate the bile ducts, and may reduce the risk for bile duct injury and other complications. Previous studies have compared ICG with conventional visualization showing shorter operation time and lower conversion rates during LC performed with traditional operation techniques. Results from LC performed with the Fundus First method (FF-LC) and ICG fluorescence has not been previously reported. The aim of this retrospective study was to compare LC with and without the aid of ICG fluorescence at a Swedish hospital routinely performing FF-LC.

Iatrogenic bile duct injuries (BDIs) prevention during laparoscopic cholecystectomy (LC) relies on meticulous anatomical dissections through direct visualization. Near-infrared fluorescence (NIRF) with indocyanine green (ICG) improves the visualization of extrahepatic biliary structures. Although ICG can be administered either intravenously or intragallbladder, there remains uncertainty regarding the optimal method for different patient populations. This study sought to assess the suitability of each method for specific patient groups.Between October 2021 and May 2022, 59 consecutive patients underwent fluorescence-guided LC at West China Hospital of Sichuan University. Among them, 32 patients received an intravenous injection of ICG (10 mg) 10 to 12 hours prior to surgery (Group A: the intravenous group), while 27 patients received an intragallbladder injection of ICG (10 mg) (Group B: the intragallbladder group). Baseline clinical factors, inclusion criteria, and measurements of parameters and complications were assessed. Data were retrospectively collected and analyzed to evaluate the comparability of the two groups and the clinical outcomes.Groups A and B included 32 patients (18 males, 14 females), and 27 patients (13 men, 14 women), respectively. In our statistical analysis, significant differences were observed in preoperative diagnoses between the two groups (P=0.041), but the majority of other baseline clinical factors were comparable. Notably, no statistically significant differences were found in complication rates. However, Group A had a shorter operative time (60.38±9.35 66.78±9.88 min, P=0.01) and superior bile duct fluorescence (P=0.04) than Group B. Interestingly, fluorescence was not observed in impacted gallbladder stones in Group B. Additionally, patients with cirrhosis (P=0.008) and fatty liver (P=0.005) in Group B had higher common bile duct-to-liver ratios (BLRs) than those in Group A.ICG fluorescence cholangiography allows to visualize extrahepatic biliary anatomical structures with both administration methods. However, the efficacy of bile duct fluorescence varies with different administration routes in diverse patient populations. Hence, appropriate administration route selection for ICG should be tailored to individual patients.2024 AME Publishing Company. All rights reserved.

Bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is a dreaded complication. Artificial intelligence (AI) has recently been introduced in surgery. This systematic review aims to investigate whether AI can guide surgeons in identifying anatomical structures to facilitate safer dissection during LC.

According to the National Clinical Database of Japan, the incidence of bile duct injury (BDI) during laparoscopic cholecystectomy has hovered around 0.4% for the last 10 years and has not declined. On the other hand, it has been found that about 60% of BDI occurrences are due to misidentifying anatomical landmarks. However, the authors developed an artificial intelligence (AI) system that gave intraoperative data to recognize the extrahepatic bile duct (EHBD), cystic duct (CD), inferior border of liver S4 (S4), and Rouviere sulcus (RS). The purpose of this research was to evaluate how the AI system affects landmark identification.

We comparatively analyzed the longitudinal outcomes of conversion to open procedure, laparoscopic subtotal cholecystectomy (CCY), and laparoscopic cholecystostomy tube placement.

Several studies seem to indicate at least a 2-fold increase in bile duct injuries (BDI) since the inception of laparoscopic cholecystectomy. Moreover, injuries seem to be more proximal, seem to be revealed earlier, are expressed by leaks more often than by strictures, are repaired more frequently by nonspecialists (either during the index operation or soon after), and appear to be more often associated with loss of substance and ischemia. The plethora of prior classifications probably attests to the evolving clinical spectrum, the mounting wealth of ever-increasing diagnostic methods, and an acknowledgment of insufficiencies or lack of data in earlier classification reports. Previous attempts at uniformity remain incomplete. The purpose of this study was to devise a nominal classification, combining all existing classification items, taking into account the changing pattern of BDI.Extensive bibliographic research, analysis of each category within the individual classifications combined into one uniform classification.Fifteen classifications were retained. All items were integrated into the European Association for Endoscopic Surgery (EAES) classification, using semantic connotations, grouped in three easy-to-remember categories, A (for anatomy), To (for time of), M (for mechanism): (1) the anatomic characteristics of the injury: NMBD for non-main bile duct or MBD for main bile duct (followed by a number 1-6, corresponding to the anatomic level on the MBD), followed by Oc (for occlusion) or D (division), P (partial) or C (complete), LS (loss of substance), VBI (vasculobiliary injury in general), and whenever known, the vessel; (2) time of detection: Ei (early intraoperative), Ep (early postoperative) or L (late); and (3) mechanism of injury: Me (mechanical) or ED (energy-driven).The EAES composite, all-inclusive, nominal classification ATOM (anatomic, time of detection, mechanism) should allow combination of all information on BDI, irrespective of the original classification used, and thus facilitate epidemiologic and comparative studies; indicate simple, appropriate preventive measures; and better guide therapeutic indications for iatrogenic BDI occurring during cholecystectomy.

&lt;b&gt;<i>Background:</i>&lt;/b&gt; Bile duct injury (BDI) is a devastating complication following cholecystectomy. After initial management of BDI, patients stay at risk for late complications including anastomotic strictures, recurrent cholangitis, and secondary biliary cirrhosis. &lt;b&gt;<i>Methods:</i>&lt;/b&gt; We provide a comprehensive overview of current literature on the long-term outcome of BDI. Considering the availability of only limited data regarding treatment of anastomotic strictures in literature, we also retrospectively analyzed patients with anastomotic strictures following a hepaticojejunostomy (HJ) from a prospectively maintained database of 836 BDI patients. &lt;b&gt;<i>Results:</i>&lt;/b&gt; Although clinical outcomes of endoscopic, radiologic, and surgical treatment of BDI are good with success rates of around 90%, quality of life (QoL) may be impaired even after “clinically successful” treatment. Following surgical treatment, the incidence of anastomotic strictures varies from 5 to 69%, with most studies reporting incidences around 10–20%. The median time to stricture formation varies between 11 and 30 months. Long-term BDI-related mortality varies between 1.8 and 4.6%. Of 91 patients treated in our center for anastomotic strictures after HJ, 81 (89%) were treated by percutaneous balloon dilatation, with a long-term success rate of 77%. Twenty-four patients primarily or secondarily underwent surgical revision, with recurrent strictures occurring in 21%. &lt;b&gt;<i>Conclusions:</i>&lt;/b&gt; The long-term impact of BDI is considerable, both in terms of clinical outcomes and QoL. Treatment should be performed in tertiary expert centers to optimize outcomes. Patients require a long-term follow-up to detect anastomotic strictures. Strictures should initially be managed by percutaneous dilatation, with surgical revision as a next step in treatment.

High-biliary injuries are associated with worse outcomes. Most series do not mention failure rates specific to the injury grade. In our experience, Strasberg E4 injuries are associated with a higher failure rate. This study shares our experience with the surgical management of postcholecystectomy Strasberg E4 injuries.Patient demographics, radiological findings, operative details, and postoperative complications were collected for patients with Strasberg E4 injury from October 2003 to December 2020. Between 2003 and 2010, the preferred operation was Roux-en-Y hepaticojejunostomy (HJ). In cases of right lobe atrophy or an isolated right hepatic duct injury, a primary hepatic resection was considered. From 2010 onward, Strasberg E4 injuries were considered for a right hepatectomy with the left duct HJ. Patients were followed up at six monthly intervals with liver function tests and abdominal ultrasound.Sixteen patients had Strasberg E4 injuries, thirteen presented with an external biliary fistula and three presented with obstructive jaundice. Nine of the ten patients who underwent HJ before 2010 developed cholangitis at a median follow-up of 14 months (2-28 months). Five of these subsequently underwent a hepatectomy, one underwent a liver transplant, and the other three underwent radiological dilatation of their anastomoses. From 2010 onward, six patients underwent an upfront right hepatectomy with left duct anastomosis. At a median follow-up of 40 months (10-74 months), 3 patients had minor derangement of liver enzymes, and none required an endoscopic or radiological intervention.HJ in E4 injuries often produces poor long-term results. An upfront right hepatectomy with left duct anastomosis might be considered.© 2025 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).

Complete transection of the main bile duct (CTMD) is a major complication during hepato-bilio-pancreatic (HBP) surgery and is associated with high morbidity and mortality. In recent years, a combined endoscopic-radiological approach (CERA) for minimally invasive treatment of CTMD has been introduced, but evidence on its long-term outcomes is limited. Our aim is to report efficacy, safety, and long-term outcomes of CERA for the management of post-surgical CTMD in a tertiary referral center.All consecutive patients referred for CTMD after HBP surgery between February 2012 and January 2021 were included in this study. CERA was first performed to re-establish biliary tree continuity, and then multiple biliary plastic stents were deployed to guarantee biliary tree reconstruction. Anthropometric, clinical, procedural (endoscopic/radiologic/surgical), and follow-up data were collected and analyzed. Each lesion was classified according to Strasberg classification.Overall, 60 patients (age 60.5 years, range 28-91), 38 F (61.7%), underwent CERA. Mean interval from surgery to endoscopic treatment was 13.2 days. Mean treatment duration was 526 days (SD ± 415) with a median number of 8 endoscopic sessions (range 1-33). Mean length of the biliary defect was 17.6 mm (SD ± 11.5). Long-term clinical success was achieved in 33/49 (67.3%) of patients. Treatment failure was experienced in 16/49 (32.7%) patients, while after an average follow-up of 41 months, stricture recurrence was observed in 3/36 (8.3%) patients.CERA is a minimally invasive and effective technique to re-establish the continuity of the biliary tract after CTMD, achieving permanent restoration in over half of treated patients.© 2022. The Society for Surgery of the Alimentary Tract.

Background: Post-cholecystectomy bile duct injuries (BDIs) represent a challenging complication, with negative impacts on clinical outcomes. Several surgical and endoscopic/interventional radiologist (IR) approaches have been proposed to manage these damages, though with high failure rates. This individual patient data (IPD) systematic review analyzes the potential risk factors for failure after treatment interventions for BDIs, both surgical and endoscopic/IR. Methods: An extensive literature search was conducted on MEDLINE and Scopus for relevant articles published in English on the management of BDIs after cholecystectomy, between 1 January 2010 and 31 December 2023. Our series of BDIs was included. BDIs were always categorized according to the Strasberg’s classification. The composite primary endpoints evaluated were the failure of treatment interventions, defined as patient death or the requirement of any other procedure, whatever surgical and/or endoscopic/IR, after the primary treatment. Results: A total of 342 cases were retrieved from our literature analysis, including our series of 19 patients. Among these, three groups were identified: “upfront surgery”, “upfront endoscopy and/or IR” and “no upfront treatment”, consisting of 224, 109 and 9 patients, respectively. After eliminating the third group, treatment intervention failure was observed overall in 34.2% (114/333) of patients, of whom 80.7% (92/114) and 19.3% (22/114) in the “upfront surgery” and in the “upfront endoscopy/IR” groups, respectively. At multivariable analysis, injury type D and E, and repair in a non-specialized center represented independent predictors of treatment failure in both groups, whereas laparoscopic cholecystectomy (LC) converted to open and immediate attempt of surgical repair exclusively in the first group. Conclusions: Significant treatment failure rates are responsible for remarkable negative effects on immediate and longer-term clinical outcomes of post-cholecystectomy BDIs. Understanding the important risk factors for this outcome may better guide the most appropriate therapeutical approach and improve clinical decisions in case this serious complication occurs.