Postcholecystectomy benign biliary stricture: Surgery is the gold standard

Post cholecystectomy bile duct strictures present a challenge to the treating physicians. Advancement in skills and technology offers alternative treatment modalities to the standard surgical repair. Contemporary series of surgical repair by experienced surgeons report excellent long-term results with <5% restricture rates. Endoscopic therapy is conceptually flawed, is not applicable to all patients, requires prolonged duration of treatment with multiple interventions. Surgical repair by an experienced surgeon is the “Gold Standard” of care in management of postcholecystectomy bile duct strictures

Internal drainage of liver hydatid - concerns and solutions

There are a number of procedures for the surgical management of liver hydatid and controversies still persist regarding the best technique Forty-three patients with hydatid disease of the liver were managed surgically between 1991 and 1998. Internal drainage (Roux-en-Y cysto-jejunostomy) was performed in eight cases of liver hydatid with biliary communications. Internal drainage was associated with a high incidence of the infection of the residual cavity with abscess formation (n=3/8, 38%). In all the three patients the cyst was located in the superior segments of the liver (VII, VIII, IVa). In two of the three patients the cyst was larger than 10 cm. Dependent siting of stoma is a key for the successful outcome of internal drainage in liver hydatid. This procedure is best avoided in large cysts, especially those located in the superior segments and with pericyst calcification

Surgical management of patients with post-cholecystectomy benign biliary stricture complicated by atrophy–hypertrophy complex of the liver

AbstractBackgroundAtrophy–hypertrophy complex (AHC) of the liver rarely complicates post-cholecystectomy benign biliary strictures (BBS). This study aimed to analyse the effect of AHC on the surgical management of patients with BBS.MethodsBetween 1989 and 2005, 362 patients underwent surgical repair for BBS at a tertiary referral centre in northern India. A total of 36 (10%) patients had AHC. Patients with AHC (n= 36) were compared with those without (n= 336) to define the factors associated with the development of AHC.ResultsOverall, 35 patients with AHC underwent Roux-en-Y hepaticojejunostomy; right hepatectomy was performed in one patient. The interval between bile duct injury and stricture repair did not influence the development of AHC (mean 24 months in AHC patients vs. 19 months in non-AHC patients; P= 0.522). Of the 36 patients with AHC, 26 (72%) had hilar strictures (Bismuth's types III, IV, V), as did 163 of the 326 (50%) patients without AHC (P= 0.012). Patients with AHC had more blood loss at surgery (mean blood loss 340ml in the AHC group vs. 190ml in the non-AHC group; P= 0.004) and required more blood transfusion (mean blood transfused 300ml vs. 120ml; P= 0.001). Surgery was prolonged in AHC patients (mean duration of operation 4.2 hours in the AHC group vs. 2.8 hours in the non-AHC group; P= 0.001). Over a mean follow-up of 43 months (range 6–163 months), three of 36 (8%) AHC patients required re-intervention for recurrent strictures, compared with nine of 326 (3%) non-AHC patients (P= 0.006).ConclusionsIatrogenic injury at the hepatic hilum predisposes for the development of AHC. Surgery is more difficult and blood transfusion requirements are higher in patients with AHC during surgical repair of BBS. Atrophy–hypertrophy complex is a risk factor for recurrent stricture formation after hepaticojejunostomy