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Vol. 7, No. 2 2003
death. R0 resections were possible in 5 cases. Helical CT, MRCP, angiogram, and precise cholangiogram were employed for pre-operative diagnosis. We show a typical case to show how to decide operative procedure. The case is 67 year-old-male. Posterior sector bile duct and lateral sector bile duct had stenosis and invasion to left portal vein bifurcation was diagnosed. Left t trisectionectomy or segment 4, 5, 8 resection with portal vein resection was planned at first. By 3D-CT volumetry, posterior segment was small, so we selected segment 4, 5, 8 resection. Right portal vein was reconstructed by end to end anastomosis, and left portal vein by side to end anastomosis using external iliac vein graft. Three posterior sector bile ducts and three lateral sector bile ducts were anastomosed to jejunum with a Roux-Y loop. All bile duct margins were free from cancer microscopically. The maximum serum total bilirubin level was 10.9 mg/dl on the first operative day. The post-operative course was uneventful. We reported our recent experiences of type 4 hilar bile duct carcinoma. Rationale operation can be possible with precise pre-operative diagnosis and simulation.
155 Extrahepatic Bile Duct Injury During Laparoscopic Cholecystectomy Andrea Frilling, Massimo Malago, Giuliano Testa, Jun Li, Christoph E Broelsch, University Hospital Essen, Essen, Germany; University of Illinois at Chicago, Chicago, IL Background: Despite clear advantages of laparoscopic cholecystectomy, the injury of hilar structures, particularly of the common bile duct, remains the subject of continuous discussion. Materials/Methods: From April 1998 till September 2002, 33 patients with damage of extrahepatic bile duct during laparoscopic cholecystectomy were referred to our institution. All patients underwent elective surgery because of symptomatic cholelithiasis in a hospital elsewhere. In 5 of these patients, the bile duct damage was diagnosed at the time of laparoscopic procedure leading to conversion to open surgery. In 3 other patients the bile duct damage was recognized early postoperatively and endoscopic bile duct stenting was performed subsequently. All 33 patients underwent laparotomy in our institution. Results: Complete transection of the common bile duct was present in 29 patients. In 2 patients iatrogene stenosis of the common bile duct was found. Two patients had significant tangential duct lesions. Of the patients with complete bile duct dissection, in 4 individuals damage of the common hepatic artery and right hepatic artery, respectively, took place. Reconstructive surgery included Roux-en-Y bilioenteric anastomosis in 31 cases, in 3 of them over endoluminal drain. Additionally, in 2 of the patients, reconstruction of the hepatic artery was performed. Two patients required right hepatectomy. In one of these patients a Klatskin tumor not recognized at the time of laparoscopy was disclosed. The postoperative outcome was uneventful in 30 patients. Intraabdominal abscess required relaparotomy in one patient. Two patients with complex bile duct and arterial damage died postoperatively, one in septic organ failure and the other one due to hepatic insufficiency while waiting for liver transplantation. Conclusion: Injury of common bile duct presents a dangerous and potentially lethal complication of laparoscopic cholecystectomy, in particular in cases of concomitant vascular injuries. Early recognition of the lesion is extremely important. It is advisable to treat these patients in specialized centers since their management frequently requires advanced knowledge in hepatobiliary surgery.
156 The Implications of Male Gender on Outcomes of Cholecystectomy James T Kakuda, David Smith, Rebecca R Schwarz, Lawrence D Wagman, Christian DeVirgilio, City of Hope National Medical Center, Duarte, CA; Harbor-UCLA Medical Center, Torrance, CA Background: Little data exists regarding the impact of male gender upon the outcome of cholecystectomy for symptomatic cholelithiasis. Objective: The purpose of this study is to determine the impact of male
Abstracts
307
gender on outcome of cholecystectomy in terms of the incidence of acute and gangrenous cholecystitis, the rate of conversion from laparoscopic to open cholecystectomy, and the incidence of biliary complication. Setting: A university-affiliated urban hospital. Methods: All patients undergoing cholecystectomy at a single institution from January 1996 to March 1999 were included in this analysis. Data was tabulated from hospital records and analyzed with appropriate statistical methods. Results: 1070 patients underwent cholecystectomy over the study period. 908 (84.9%) patients were female (M: F ratio 1:5.6). Patient ethnicity was Hispanic in 829 (77.5%), White in 73 (6.8%), African-American in 34 (3.2%), Asian in 28 (2.6%), and not defined in 106 (10%). 817 (76.4%) procedures were laparoscopic, 204 (19.1%) were converted from laparoscopic to open and 49 (4.6%) were open. The indications for cholecystectomy were as follows: 471 (44%) biliary colic, 380 (36%) acute cholecystitis, 145 (13.6%) gallstone pancreatitis, 63 (5.9%) choledocholithiasis, and 11 (1.3%) other. Biliary complications were comprised of bile leak and biloma in 25 (2.3%) cases and bile duct injury in 10 (0.93%). In univariate analysis, men were more likely to undergo cholecystectomy for acute cholecystitis (39.5% vs. 23.3%, p 0.0001), develop gangrenous cholecystitis (25.3% vs. 11.2%, p710-6), require conversion to open cholecystectomy (42.8% vs. 16.1%, p 10-16) and suffer biliary complication (7.4% vs. 2.6%, p0.04). Male gender was found to be independent of age, race, surgical indication, and length of preoperative hospitalization in a multivariate analysis. Conclusion: Male gender is associated with acute cholecystitis, gangrenous cholecystitis, conversion to open cholecystectomy and biliary complication. Results of Multivariate Analysis Endpoint Acute cholecystitis Gangrenous cholecystitis Conversion to open Biliary complication
Odds ratio with male gender
95% CI
2.08 2.57 3.24 2.79
145–2.97 1.69–3.91 2.23–4.70 1.36–5.75
All p-values less than 0.001.
157 Biliary Reconstruction: Can Classic Techniques Meet New Challenges? James Guarrera, Prashant Sinha, John D Allendorf, Milan Kinkhabwala, Robert S Brown Jr, Jean C Emond, New York Presbyterian Hospital, Riverdale, NY Introduction: Classic techniques in biliary surgery were developed to treat common duct strictures after cholecystectomy. In the past decade, the expansion of hepatic surgery has required more complex reconstructions using either primary or bilio-intestinal anastomosis. We analyzed the incidence of leak and stricture as a function of the complexity of the reconstruction in all cases requiring biliary reconstruction. Methods: Between 1/1/98 and 12/1/01, 231 reconstructions were performed 62 pediatric and 169 adult cases in 4 indications: 181 primary transplants (PT), 23 transplant revisions (TR), 19 benign obstructions (BO), 8 malignant obstruction (MO). Among PT, 120 were standard OLT while 34 were right lobe grafts (RL), 14 left lobe (L), and 31 left lateral segment (LL). Biliary intubations (T-tube or stent) were used in 30 (13%). Fifty-five had multiple duct anastomoses (MDA)(24%), with 2 duct (37:67%), 3 ducts (13:24%), or 4 ducts (3: 5%). Results: Leaks occurred in 12.5% of MO, 5% of BO, 12.7% of PT and 0% TR (p.25). Neither leaks (12.7% vs 11%) nor strictures (12% vs 16%) were more common in MDA. Leaks were most common (34%) after RL transplants (p.019). Strictures occurred in 12.5% of MO, 5% of BO, 16% of PT and 15% TR (p.77). Strictures were most common (29%) after LL transplants (p.0012). Interventional (25%) or endoscopic procedures (5.6%) were required in 67 patients overall (29%). The actuarial stricture or leak free
death. R0 resections were possible in 5 cases. Helical CT, MRCP, angiogram, and precise cholangiogram were employed for pre-operative diagnosis. We show a typical case to show how to decide operative procedure. The case is 67 year-old-male. Posterior sector bile duct and lateral sector bile duct had stenosis and invasion to left portal vein bifurcation was diagnosed. Left t trisectionectomy or segment 4, 5, 8 resection with portal vein resection was planned at first. By 3D-CT volumetry, posterior segment was small, so we selected segment 4, 5, 8 resection. Right portal vein was reconstructed by end to end anastomosis, and left portal vein by side to end anastomosis using external iliac vein graft. Three posterior sector bile ducts and three lateral sector bile ducts were anastomosed to jejunum with a Roux-Y loop. All bile duct margins were free from cancer microscopically. The maximum serum total bilirubin level was 10.9 mg/dl on the first operative day. The post-operative course was uneventful. We reported our recent experiences of type 4 hilar bile duct carcinoma. Rationale operation can be possible with precise pre-operative diagnosis and simulation.
155 Extrahepatic Bile Duct Injury During Laparoscopic Cholecystectomy Andrea Frilling, Massimo Malago, Giuliano Testa, Jun Li, Christoph E Broelsch, University Hospital Essen, Essen, Germany; University of Illinois at Chicago, Chicago, IL Background: Despite clear advantages of laparoscopic cholecystectomy, the injury of hilar structures, particularly of the common bile duct, remains the subject of continuous discussion. Materials/Methods: From April 1998 till September 2002, 33 patients with damage of extrahepatic bile duct during laparoscopic cholecystectomy were referred to our institution. All patients underwent elective surgery because of symptomatic cholelithiasis in a hospital elsewhere. In 5 of these patients, the bile duct damage was diagnosed at the time of laparoscopic procedure leading to conversion to open surgery. In 3 other patients the bile duct damage was recognized early postoperatively and endoscopic bile duct stenting was performed subsequently. All 33 patients underwent laparotomy in our institution. Results: Complete transection of the common bile duct was present in 29 patients. In 2 patients iatrogene stenosis of the common bile duct was found. Two patients had significant tangential duct lesions. Of the patients with complete bile duct dissection, in 4 individuals damage of the common hepatic artery and right hepatic artery, respectively, took place. Reconstructive surgery included Roux-en-Y bilioenteric anastomosis in 31 cases, in 3 of them over endoluminal drain. Additionally, in 2 of the patients, reconstruction of the hepatic artery was performed. Two patients required right hepatectomy. In one of these patients a Klatskin tumor not recognized at the time of laparoscopy was disclosed. The postoperative outcome was uneventful in 30 patients. Intraabdominal abscess required relaparotomy in one patient. Two patients with complex bile duct and arterial damage died postoperatively, one in septic organ failure and the other one due to hepatic insufficiency while waiting for liver transplantation. Conclusion: Injury of common bile duct presents a dangerous and potentially lethal complication of laparoscopic cholecystectomy, in particular in cases of concomitant vascular injuries. Early recognition of the lesion is extremely important. It is advisable to treat these patients in specialized centers since their management frequently requires advanced knowledge in hepatobiliary surgery.
156 The Implications of Male Gender on Outcomes of Cholecystectomy James T Kakuda, David Smith, Rebecca R Schwarz, Lawrence D Wagman, Christian DeVirgilio, City of Hope National Medical Center, Duarte, CA; Harbor-UCLA Medical Center, Torrance, CA Background: Little data exists regarding the impact of male gender upon the outcome of cholecystectomy for symptomatic cholelithiasis. Objective: The purpose of this study is to determine the impact of male
Abstracts
307
gender on outcome of cholecystectomy in terms of the incidence of acute and gangrenous cholecystitis, the rate of conversion from laparoscopic to open cholecystectomy, and the incidence of biliary complication. Setting: A university-affiliated urban hospital. Methods: All patients undergoing cholecystectomy at a single institution from January 1996 to March 1999 were included in this analysis. Data was tabulated from hospital records and analyzed with appropriate statistical methods. Results: 1070 patients underwent cholecystectomy over the study period. 908 (84.9%) patients were female (M: F ratio 1:5.6). Patient ethnicity was Hispanic in 829 (77.5%), White in 73 (6.8%), African-American in 34 (3.2%), Asian in 28 (2.6%), and not defined in 106 (10%). 817 (76.4%) procedures were laparoscopic, 204 (19.1%) were converted from laparoscopic to open and 49 (4.6%) were open. The indications for cholecystectomy were as follows: 471 (44%) biliary colic, 380 (36%) acute cholecystitis, 145 (13.6%) gallstone pancreatitis, 63 (5.9%) choledocholithiasis, and 11 (1.3%) other. Biliary complications were comprised of bile leak and biloma in 25 (2.3%) cases and bile duct injury in 10 (0.93%). In univariate analysis, men were more likely to undergo cholecystectomy for acute cholecystitis (39.5% vs. 23.3%, p 0.0001), develop gangrenous cholecystitis (25.3% vs. 11.2%, p710-6), require conversion to open cholecystectomy (42.8% vs. 16.1%, p 10-16) and suffer biliary complication (7.4% vs. 2.6%, p0.04). Male gender was found to be independent of age, race, surgical indication, and length of preoperative hospitalization in a multivariate analysis. Conclusion: Male gender is associated with acute cholecystitis, gangrenous cholecystitis, conversion to open cholecystectomy and biliary complication. Results of Multivariate Analysis Endpoint Acute cholecystitis Gangrenous cholecystitis Conversion to open Biliary complication
Odds ratio with male gender
95% CI
2.08 2.57 3.24 2.79
145–2.97 1.69–3.91 2.23–4.70 1.36–5.75
All p-values less than 0.001.
157 Biliary Reconstruction: Can Classic Techniques Meet New Challenges? James Guarrera, Prashant Sinha, John D Allendorf, Milan Kinkhabwala, Robert S Brown Jr, Jean C Emond, New York Presbyterian Hospital, Riverdale, NY Introduction: Classic techniques in biliary surgery were developed to treat common duct strictures after cholecystectomy. In the past decade, the expansion of hepatic surgery has required more complex reconstructions using either primary or bilio-intestinal anastomosis. We analyzed the incidence of leak and stricture as a function of the complexity of the reconstruction in all cases requiring biliary reconstruction. Methods: Between 1/1/98 and 12/1/01, 231 reconstructions were performed 62 pediatric and 169 adult cases in 4 indications: 181 primary transplants (PT), 23 transplant revisions (TR), 19 benign obstructions (BO), 8 malignant obstruction (MO). Among PT, 120 were standard OLT while 34 were right lobe grafts (RL), 14 left lobe (L), and 31 left lateral segment (LL). Biliary intubations (T-tube or stent) were used in 30 (13%). Fifty-five had multiple duct anastomoses (MDA)(24%), with 2 duct (37:67%), 3 ducts (13:24%), or 4 ducts (3: 5%). Results: Leaks occurred in 12.5% of MO, 5% of BO, 12.7% of PT and 0% TR (p.25). Neither leaks (12.7% vs 11%) nor strictures (12% vs 16%) were more common in MDA. Leaks were most common (34%) after RL transplants (p.019). Strictures occurred in 12.5% of MO, 5% of BO, 16% of PT and 15% TR (p.77). Strictures were most common (29%) after LL transplants (p.0012). Interventional (25%) or endoscopic procedures (5.6%) were required in 67 patients overall (29%). The actuarial stricture or leak free