Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions

Background Bile duct injury (BDI) is a dreaded complication of cholecystectomy, often caused by misinterpretation of biliary anatomy. To prevent BDI, techniques have been developed for intraoperative assessment of bile duct anatomy. This article reviews the evidence for the different techniques and discusses their strengths and weaknesses in terms of efficacy, ease, and cost-effectiveness. Method PubMed was searched from January 1980 through December 2009 for articles concerning bile duct visualization techniques for prevention of BDI during laparoscopic cholecystectomy. Results Nine techniques were identified. The critical-view-of-safety approach, indirectly establishing biliary anatomy, is accepted by most guidelines and commentaries as the surgical technique of choice to minimize BDI risk. Intraoperative cholangiography is associated with lower BDI risk (OR 0.67, CI 0.61-0.75). However, it incurs extra costs, prolongs the operative procedure, and may be experienced as cumbersome. An established reliable alternative is laparoscopic ultrasound, but its longer learning curve limits widespread implementation. Easier to perform are cholecystocholangiography and dye cholangiography, but these yield poor-quality images. Light cholangiography, requiring retrograde insertion of an optical fiber into the common bile duct, is too unwieldy for routine use. Experimental techniques are passive infrared cholangiography, hyperspectral cholangiography, and near-infrared fluorescence cholangiography. The latter two are performed noninvasively and provide real-time images. Quantitative data in patients are necessary to further evaluate these techniques. Conclusions The critical-view-of-safety approach should be used during laparoscopic cholecystectomy. Intraoperative cholangiography or laparoscopic ultrasound is recommended to be performed routinely. Hyperspectral cholangiography and near-infrared fluorescence cholangiography are promising novel techniques to prevent BDI and thus increase patient safety

Efficacy of absolute alcohol injection compared with band ligation in the eradication of esophageal varices Eficácia da injeção de álcool absoluto comparada com ligadura elástica na erradicação de varizes de esôfago

BACKGROUND: Endoscopic sclerotherapy is an absolute indication for treating esophageal varices. Re-bleeding is common during the treatment period, before all varices become eradicated. AIM: To compare two techniques of endoscopic esophageal varices eradication: sclerotherapy with absolute alcohol and banding ligation. PATIENTS AND METHOD: Forty-six patients with liver cirrhosis and esophageal varices were prospectively randomized into two treatment groups: endoscopic sclerotherapy with absolute alcohol and banding ligation. Patients were included if they had large varices with signs of high bleeding risk. Informed writing consent was obtained from every patient and the Ethics Committee of Federal University of São Paulo, SP, Brazil, approved the study. After eradication, all patients were followed up to 1 year to look for re-bleeding episodes and variceal recurrence. RESULTS: Both groups were similar except that male gender was more common in the sclerotherapy group. There was no statistical difference regarding variceal eradication (78.3% in sclerotherapy group vs 73.9% in the ligation group), recurrence (26.7% vs 42.9%, respectively) and death related to any cause (21.7% vs 13.9%). In the sclerotherapy group more sessions were need to obtain complete variceal eradication. In this group we did observe a high re-bleeding rate (34.8%) and more ulcers associated with retrosternal pain right after the procedure. There was no difference regarding overall morbidity and mortality. CONCLUSIONS: Banding ligation requires fewer sessions than sclerotherapy with absolute alcohol to eradicate esophageal varices. Both methods are equally efficient regarding variceal eradication and recurrence during a short follow-up period.<br>RACIONAL: Escleroterapia endoscópica tem indicação absoluta no tratamento das varizes de esôfago. Ressangramento é comum durante o período de tratamento, antes que as varizes sejam erradicadas. OBJETIVO: Comparar duas técnicas de erradicação endoscópica de varizes de esôfago: escleroterapia com álcool absoluto e ligadura elástica. PACIENTES E MÉTODOS: Quarenta e seis pacientes com cirrose hepática e varizes de esôfago foram prospectivamente randomizados em dois grupos de tratamento: escleroterapia endoscópica com álcool absoluto e ligadura elástica. Os pacientes foram incluídos no estudo se tivessem varizes de grosso calibre com sinais de alto risco de sangramento. Consentimento informado por escrito foi obtido de cada paciente e o estudo foi aprovado pelo Comitê de Ética da instituição onde o estudo foi realizado. Após a erradicação, todos os pacientes foram seguidos durante 1 ano para avaliar a taxa de ressangramento e a recidiva das varizes. RESULTADOS: Ambos os grupos foram parecidos exceto no que se refere ao sexo masculino, mais comum no grupo da escleroterapia. Não houve diferença estatisticamente significante em relação a erradicação das varizes (78,3% no grupo da escleroterapia vs. 73,9% no grupo da ligadura), recidiva (26,7% vs. 42,9%, respectivamente) e mortalidade relacionada a qualquer causa (21,7% vs. 13,9%). No grupo da escleroterapia houve necessidade de maior número de sessões para obtenção da erradicação completa das varizes. Neste mesmo grupo observou-se alta taxa de ressangramento (34,8%) e presença de mais úlceras associadas com dor retroesternal logo após o procedimento. Não houve diferença na morbimortalidade global. CONCLUSÕES: O tratamento com ligadura elástica requer menos sessões do que a escleroterapia com álcool absoluto para erradicar as varizes de esôfago. Ambos os métodos são igualmente eficazes, a curto prazo, no que diz respeito à taxa de erradicação e recidiva das varizes