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Bimalendu Sen - One of the best experts on this subject based on the ideXlab platform.
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iatrogenic Biliary Injury 13 305 cholecystectomies experienced by a single surgical team over more than 13 years
2008Co-Authors: Om Tantia, Mayank Jain, Shashi Khanna, Bimalendu SenAbstract:Background Biliary injuries during laparoscopic cholecystectomy (LC) are complications better avoided than treated. These injuries cause long-lasting morbidity and can be fatal. The authors present their experience with Biliary Injury in LC during a period exceeding 13 years.
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iatrogenic Biliary Injury 13 305 cholecystectomies experienced by a single surgical team over more than 13 years
2008Co-Authors: Om Tantia, Mayank Jain, Shashi Khanna, Bimalendu SenAbstract:Biliary injuries during laparoscopic cholecystectomy (LC) are complications better avoided than treated. These injuries cause long-lasting morbidity and can be fatal. The authors present their experience with Biliary Injury in LC during a period exceeding 13 years. Between January 1992 and December 2005, 13,305 LCs were performed at the authors’ institution. The Biliary injuries in these cases were recorded and analyzed retrospectively. A total of 52 Biliary injuries were identified in 13,305 LCs, for an overall incidence of 0.39%. Of these, 32 (0.24%) were diagnosed intraoperatively and 20 (0.15%) were diagnosed postoperatively. The perioperative bile duct injuries (BDIs) included 6 complete transections (5 treated by hepaticojejunostomy and 1 by primary T-tube repair (TTR), all performed by conversion to open procedure), 11 lateral BDIs (2 treated by laparoscopic choledochojejunostomy [CJ], 1 by open CJ, 5 by laparoscopic TTR, 1 by open TTR, and 2 by primary suture repair, both performed laparoscopically), 11 duct of Luschka injuries, and 4 sectoral duct injuries. The BDIs detected postoperatively included 6 patients with bilioma (treated with ultrasonography-guided aspiration), 4 patients with Biliary peritonitis (requiring relaparoscopy and peritoneal lavage and drainage followed by endoscopic retrograde cholangiography [ERC] and Biliary stenting), and 10 patients with persistent Biliary leak-controlled Biliary fistula (requiring ERC and stenting). There was no mortality related to BDI in the series. Patients with Strasberg type A/C/D injuries (46 cases) were followed 3 months to 3 years with no major complaints. Two patients with complete transection were lost to follow-up evaluation, whereas the other four patients, followed 18 months to 3 years, were asymptomatic. According to the findings, LC is a safe procedure with an incidence of Biliary Injury comparable with that for open cholecystectomy. Single-center studies such as this are important to ensure that standards of surgery are maintained in the community.
Jorge A. Bezerra - One of the best experts on this subject based on the ideXlab platform.
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Biliary atresia clinical and research challenges for the twenty first century
2018Co-Authors: Jorge A. Bezerra, Rebecca G Wells, Cara L Mack, Saul J Karpen, Jay H Hoofnagle, Edward Doo, Ronald J SokolAbstract:Biliary atresia (BA) is a fibroinflammatory disease of the intrahepatic and extrahepatic Biliary tree. Surgical hepatic portoenterostomy (HPE) may restore bile drainage, but progression of the intrahepatic disease results in complications of portal hypertension and advanced cirrhosis in most children. Recognizing that further progress in the field is unlikely without a better understanding of the underlying cause(s) and pathogenesis of the disease, the National Institutes of Diabetes and Digestive and Kidney Diseases (NIDDK) sponsored a research workshop focused on innovative and promising approaches and on identifying future areas of research. Investigators discussed recent advances using gestational ultrasound and results of newborn BA screening with serum direct (conjugated) bilirubin that support a prenatal onset of Biliary Injury. Experimental and human studies implicate the toxic properties of environmental toxins (e.g., biliatresone) and of viruses (e.g., cytomegalovirus) to the Biliary system. Among host factors, sequence variants in genes related to Biliary development and ciliopathies, a notable lack of a cholangiocyte glycocalyx and of submucosal collagen bundles in the neonatal extrahepatic bile ducts, and an innate proinflammatory bias of the neonatal immune system contribute to an increased susceptibility to damage and obstruction following epithelial Injury. These advances form the foundation for a future research agenda focused on identifying the environmental and host factor(s) that cause BA, the potential use of population screening, studies of the mechanisms of prominent fibrosis in young infants, determinations of clinical surrogates of disease progression, and the design of clinical trials that target subgroups of patients with initial drainage following HPE. (Hepatology 2018; 00:000-000).
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cxcr2 signaling and the microbiome suppress inflammation bile duct Injury and the phenotype of experimental Biliary atresia
2017Co-Authors: Junbae Jee, Reena Mourya, Pranavkumar Shivakumar, Lin Fei, Michael Wagner, Jorge A. BezerraAbstract:Biliary atresia is progressive fibro-inflammatory cholangiopathy of young children. Central to pathogenic mechanisms of Injury is the tissue targeting by the innate and adaptive immune cells. Among these cells, neutrophils and the IL-8/Cxcl-8 signaling via its Cxcr2 receptor have been linked to bile duct Injury. Here, we aimed to investigate whether the intestinal microbiome modulates Cxcr2-dependent bile duct Injury and obstruction. Adult wild-type (WT) and Cxcr2-/- mice were fed a diet supplemented with sulfamethoxazole/trimethoprim (SMZ/TMP) during pregnancy and lactation, and their pups were injected intraperitoneally with rhesus rotavirus (RRV) within 24 hours of life to induce experimental Biliary atresia. The maternal exposure to SMZ/TMP significantly lowered the incidence of jaundice and bile duct obstruction and resulted in improved survival, especially in Cxcr2-/- mice. Analyses of the microbiome by deep sequencing of 16S rRNA of the neonatal colon showed a delay in bacterial colonization of WT mice induced by SMZ/TMP, with a notable switch from Proteobacteria to Firmicutes. Interestingly, the genetic inactivation of Cxcr2 alone produced a similar bacterial shift. When treated with SMZ/TMP, Cxcr2-/- mice infected with RRV to induce experimental Biliary atresia showed further enrichment of Corynebacterium, Anaerococcus and Streptococcus. Among these, Anaerococcus lactolyticus was significantly associated with a suppression of Biliary Injury, cholestasis, and survivability. These results suggest that the postnatal development of the intestinal microbiota is an important susceptibility factor for experimental Biliary atresia.
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pathogenesis of Biliary atresia defining biology to understand clinical phenotypes
2015Co-Authors: Akihiro Asai, Alexander Miethke, Jorge A. BezerraAbstract:Biliary atresia is a severe cholangiopathy of early infancy that destroys extrahepatic bile ducts and disrupts bile flow. With a poorly defined disease pathogenesis, treatment consists of the surgical removal of duct remnants followed by hepatoportoenterostomy. Although this approach can improve the short-term outcome, the liver disease progresses to end-stage cirrhosis in most children. Further improvement in outcome will require a greater understanding of the mechanisms of Biliary Injury and fibrosis. Here, we review progress in the field, which has been fuelled by collaborative studies in larger patient cohorts and the development of cell culture and animal model systems to directly test hypotheses. Advances include the identification of phenotypic subgroups and stages of disease based on clinical, pathological and molecular features. Stronger evidence exists for viruses, toxins and gene sequence variations in the aetiology of Biliary atresia, triggering a proinflammatory response that injures the duct epithelium and produces a rapidly progressive cholangiopathy. The immune response also activates the expression of type 2 cytokines that promote epithelial cell proliferation and extracellular matrix production by nonparenchymal cells. These advances provide insight into phenotype variability and might be relevant to the design of personalized trials to block progression of liver disease.
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Biliary Atresia- Translational Research on Key Molecular Processes Regulating Biliary Injury and Obstruction
2015Co-Authors: Jorge A. BezerraAbstract:Biliary atresia is the most common cause of pathologic jaundice in young infants and results from the obstruction of the extrahepatic bile ducts by an inflammatory and fibro-obliterative process. Although the pathogenesis of the disease is multifactorial, recent patient- and animal-based studies began deciphering the molecular pathways involved in bil-iary Injury and duct obstruction. Using large-scale genomics and immunostaining of livers from children with Biliary atresia, investigators have discovered unique molecular signatures of dominant proinflammatory cytokines at the time of diagnosis. To study hypotheses gener-ated from these patient-based studies, the anatomical and inflammatory profiles of a mouse model of rotavirus-induced Biliary atresia were analyzed and found to share striking similar-ities with the human profiles. Then, using these mice in mechanistic studies, interferon-gamma (IFNγ) has been shown to regulate the Biliary tropism of lymphocytes to the Biliary system, and to play a critical role in the inflammatory obstruction of extrahepatic bile ducts. The ability to combine human studies with a laboratory model of neonatal Biliary Injury and obstruction opens a new era of opportunities to advance the field of Biliary atresia, and to develop new therapeutic strategies to improve long-term outcome with the native liver of children with Biliary atresia. (Chang Gung Med J 2006;29:222-30
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dendritic cells regulate natural killer cell activation and epithelial Injury in experimental Biliary atresia
2011Co-Authors: Vijay Saxena, Reena Mourya, Pranavkumar Shivakumar, Gregg Sabla, Claire A Chougnet, Jorge A. BezerraAbstract:Biliary atresia is the most common cholangiopathy of childhood. During infancy, an idiopathic activation of the neonatal immune system targets the Biliary epithelium, obstructs bile ducts, and disrupts the anatomic continuity between the liver and the intestine. Here, we use a model of virus-induced Biliary atresia in newborn mice to trace the initiating pathogenic disease mechanisms to resident plasmacytoid (pDCs) and conventional (cDCs) dendritic cells. We found pDCs to be the most abundant DC population in the livers of newborn mice, and we observed pDCs in the livers of infants at the time of diagnosis. In the livers of newborn mice, cDCs spontaneously overexpressed the costimulatory molecule CD80 soon after birth, and pDCs produced the cytokine interleukin-15 (IL-15) in response to a virus insult. Both subtypes of primed DCs were required for the proliferation of T lymphocytes and the activation of natural killer cells. Disruption of this cellular network by depletion of pDCs or blockade of IL-15 signaling in mice in vivo prevented epithelial Injury, maintained anatomic continuity of the bile duct, and promoted long-term survival. These findings identify cellular triggers of Biliary Injury and have implications for future therapies to block the progression of Biliary atresia and liver disease.
Om Tantia - One of the best experts on this subject based on the ideXlab platform.
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iatrogenic Biliary Injury 13 305 cholecystectomies experienced by a single surgical team over more than 13 years
2008Co-Authors: Om Tantia, Mayank Jain, Shashi Khanna, Bimalendu SenAbstract:Background Biliary injuries during laparoscopic cholecystectomy (LC) are complications better avoided than treated. These injuries cause long-lasting morbidity and can be fatal. The authors present their experience with Biliary Injury in LC during a period exceeding 13 years.
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iatrogenic Biliary Injury 13 305 cholecystectomies experienced by a single surgical team over more than 13 years
2008Co-Authors: Om Tantia, Mayank Jain, Shashi Khanna, Bimalendu SenAbstract:Biliary injuries during laparoscopic cholecystectomy (LC) are complications better avoided than treated. These injuries cause long-lasting morbidity and can be fatal. The authors present their experience with Biliary Injury in LC during a period exceeding 13 years. Between January 1992 and December 2005, 13,305 LCs were performed at the authors’ institution. The Biliary injuries in these cases were recorded and analyzed retrospectively. A total of 52 Biliary injuries were identified in 13,305 LCs, for an overall incidence of 0.39%. Of these, 32 (0.24%) were diagnosed intraoperatively and 20 (0.15%) were diagnosed postoperatively. The perioperative bile duct injuries (BDIs) included 6 complete transections (5 treated by hepaticojejunostomy and 1 by primary T-tube repair (TTR), all performed by conversion to open procedure), 11 lateral BDIs (2 treated by laparoscopic choledochojejunostomy [CJ], 1 by open CJ, 5 by laparoscopic TTR, 1 by open TTR, and 2 by primary suture repair, both performed laparoscopically), 11 duct of Luschka injuries, and 4 sectoral duct injuries. The BDIs detected postoperatively included 6 patients with bilioma (treated with ultrasonography-guided aspiration), 4 patients with Biliary peritonitis (requiring relaparoscopy and peritoneal lavage and drainage followed by endoscopic retrograde cholangiography [ERC] and Biliary stenting), and 10 patients with persistent Biliary leak-controlled Biliary fistula (requiring ERC and stenting). There was no mortality related to BDI in the series. Patients with Strasberg type A/C/D injuries (46 cases) were followed 3 months to 3 years with no major complaints. Two patients with complete transection were lost to follow-up evaluation, whereas the other four patients, followed 18 months to 3 years, were asymptomatic. According to the findings, LC is a safe procedure with an incidence of Biliary Injury comparable with that for open cholecystectomy. Single-center studies such as this are important to ensure that standards of surgery are maintained in the community.
Robert J. Porte - One of the best experts on this subject based on the ideXlab platform.
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ex vivo normothermic machine perfusion and viability testing of discarded human donor livers
2013Co-Authors: Op Den S Dries, Henri G D Leuvenink, Negin Karimian, Andrie C. Westerkamp, Ton Lisman, Michael E Sutton, Maarten W N Nijsten, Annette S H Gouw, Jantje Wiersemabuist, Robert J. PorteAbstract:In contrast to traditional static cold preservation of donor livers, normothermic machine perfusion may reduce preservation Injury, improve graft viability and potentially allows ex vivo assessment of graft viability before transplantation. We have studied the feasibility of normothermic machine perfusion in four discarded human donor livers. Normothermic machine perfusion consisted of pressure and temperature controlled pulsatile perfusion of the hepatic artery and continuous portal perfusion for 6 h. Two hollow fiber membrane oxygenators provided oxygenation of the perfusion fluid. Biochemical markers in the perfusion fluid reflected minimal hepatic Injury and improving function. Lactate levels decreased to normal values, reflecting active metabolism by the liver (mean lactate 10.0 ± 2.3 mmol/L at 30 min to 2.3 ± 1.2 mmol/L at 6 h). Bile production was observed throughout the 6 h perfusion period (mean rate 8.16 ± 0.65 g/h after the first hour). Histological examination before and after 6 h of perfusion showed well-preserved liver morphology without signs of additional hepatocellular ischemia, Biliary Injury or sinusoidal damage. In conclusion, this study shows that normothermic machine perfusion of human donor livers is technically feasible. It allows assessment of graft viability before transplantation, which opens new avenues for organ selection, therapeutic interventions and preconditioning.
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protection of bile ducts in liver transplantation looking beyond ischemia
2011Co-Authors: Sanna Op Den Dries, Ton Lisman, Michael E Sutton, Robert J. PorteAbstract:Biliary complications, especially nonanastomotic Biliary strictures (NAS), are a major cause of morbidity after orthotopic liver transplantation. Of all donor and recipient characteristics known to increase the risk of developing NAS, the role of prolonged ischemia times is most extensively described in the literature. However, there is increasing evidence that several other, non-ischemia-related factors play a critical role in the pathogenesis of NAS as well. The clinical presentation of NAS may vary considerably among liver transplant recipients, including large variations in time of occurrence, and in location and severity of the strictures. Additional underlying causes such as bile salt toxicity and immune-mediated Injury are believed to explain the wide spectrum of Biliary strictures after orthotopic liver transplantation. Current and emerging insight in the pathogenesis of NAS and potential targets to reduce Biliary Injury and preserve bile ducts are discussed in this overview.
Steven M Strasberg - One of the best experts on this subject based on the ideXlab platform.
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a simple effective method for generation of a permanent record of the critical view of safety during laparoscopic cholecystectomy by intraoperative doublet photography
2014Co-Authors: Dominic E Sanford, Steven M StrasbergAbstract:Background The Critical View of Safety (CVS) is an established method for identifying the cystic duct during laparoscopic cholecystectomy. Its goal is to prevent misidentification of the bile ducts and avoid Biliary Injury. However, a visual record of CVS is not usually made. Intraoperative photography has the potential to record CVS and increase the safety of laparoscopic cholecystectomy. The objective of this study was to develop a simple and effective technique for recording CVS during laparoscopic cholecystectomy. Study Design Techniques for photographing and rating photographs of CVS were developed. Surgeons were trained in methods of photographing both anterior and posterior views of CVS during laparoscopic cholecystectomy. Independent observers scored these views individually and together. The term doublet view was used when both anterior and posterior views of CVS were used for rating. Three criteria for CVS were used for scoring photographs. A total score of ≥5 of 6 points was considered satisfactory, and a total score Results Photographs of 28 patients were obtained. Critical View of Safety photographs were satisfactory in either anterior or posterior single images in 43 of 56 (76.8%) instances, and doublet photographs were satisfactory in 27 of 28 (96.4%) instances (p = 0.02). Body mass index >40 predicted a higher likelihood of unsatisfactory individual CVS photos (p = 0.02); however, there was no correlation between patient or pathologic factors and the scores of doublet views. Conclusions With training and adherence to straightforward photographic techniques, intraoperative doublet photography can record CVS accurately. This method is performed easily, and could be used for recording of CVS in the medical record.
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rationale and use of the critical view of safety in laparoscopic cholecystectomy
2010Co-Authors: Steven M Strasberg, Michael L BruntAbstract:t l c t d t t a c c m t c p o l c b q t f d t s f o 1 he introduction of laparoscopic cholecystectomy was associted with a sharp rise in the incidence of Biliary injuries. espite the advancement of laparoscopic cholecystectomy echniques, Biliary Injury continues to be an important probem today, although its true incidence is unknown. The most ommon cause of serious Biliary Injury is misidentification. sually, the common bile duct is mistaken to be the cystic uct and, less commonly, an aberrant duct is misidentified as he cystic duct. The former was referred to as the “classical njury” by Davidoff and colleagues, who described the usual attern of evolution of the Injury at laparoscopic cholecystecomy. In 1995, we authored an analytical review of this subect and introduced a method of identification of the cystic tructures referred to as the “critical view of safety” (CVS) Fig. 1). (This approach to ductal identification had been decribed in 1992, but the term critical view of safety was used irst in our 1995 article.) During the past 15 years, this ethod has been adopted increasingly by surgeons around the orld for performance of laparoscopic cholecystectomy. hen the method was initially described, it was done so with brief description and picture, without a thorough explanaion of the rationale for this approach. The primary purpose f this short communication is to present that rationale so that urgeons can better apply CVS by understanding why the ethod is protective against misidentification. A second purose is to review the current status of the use of CVS and to uggest approaches that might reduce the incidence of Biliary njury through its use.
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Biliary Injury after laparoscopic cholecystectomy in a patient with right liver agenesis case report and review of the literature
2008Co-Authors: Ryan C Fields, Jay P Heiken, Steven M StrasbergAbstract:An 87-year-old man underwent attempted laparoscopic cholecystectomy. The procedure was characterized by significant inflammation and bleeding requiring conversion to an open procedure. Postoperatively, the patient had continued bile drainage from his surgical drain. He was referred to our institution and found to have complete transection of his common bile duct. Incidentally, he was noted on imaging studies to have absence of his right liver with associated left liver hypertrophy. This was characterized by complete absence of the right portal vein and right bile duct. Review of his preoperative imaging confirmed this finding of right liver agenesis and very unusual hepatic vein anatomy. This represents the first reported case of bile duct Injury in the setting of right liver agenesis. We review the details of the case and the natural history of agenesis of a hemiliver.
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error traps and vasculo Biliary Injury in laparoscopic and open cholecystectomy
2008Co-Authors: Steven M StrasbergAbstract:Many Biliary misidentification injuries occur due to error traps-methods that work well in most circumstances but which are apt to under certain conditions. We have identified four such traps from an extensive experience in repair of Biliary injuries. The most common cause of misidentification results from the “infundibular technique” error trap. This problem is usually associated with severe inflammation which hides the cystic duct and obliterates the triangle of Calot making the common hepatic duct appear to be part to the gallbladder wall. Another error trap — the “fundus-down” cholecystectomy has been associated with injuries in which the vascular component of the Injury has been even more serious than the Biliary one ie, “vasculo-Biliary injuries” These vasulo-Biliary injuries result in hepatic infarction requiring liver resection, possibly including transplantation. As opposed to the infundibular technique error trap the fundus down error trap usually occurs at open cholecystectomy after conversion. The two other error traps are due to failure to perceive the presence of an aberrant right hepatic duct on cholangiography and Injury to the common bile duct in the case of a “parallel union” cystic duct. Knowledge of these error traps and their avoidance can help to reduce the incidence of Biliary injuries.
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Biliary Injury in laparoscopic surgery part 2 changing the culture of cholecystectomy
2005Co-Authors: Steven M StrasbergAbstract:1 his article simultaneously discusses prevention of biliry Injury and reduction of the possibility of litigation rising from nonnegligent Injury. These are considered ogether during the three periods of encounter with a atient having cholecystectomy: preoperative, operative, nd postoperative. The goals of this article are prevenion of Biliary Injury and institution of a practice aproach that will make it apparent when Injury is not rom negligence. Plaintiffs’ attorneys are guided, undertandably, by the aphorism “Where there’s smoke there’s ire,” and patients may seek out attorneys when care eems deficient even when it is not. Costly, timeonsuming legal actions, as a result, may be initiated to iscover evidence that might have been placed in the hart in the first instance. Improving the current probem of steeply spiraling costs of malpractice insurance hrough actions of those outside the profession, such as egislatures, is a worthy goal. But to pursue only that trategy is akin to asking for a good police department in community, but having faulty locks at home. It is my pinion that we, as surgeons, can have great impact on alpractice litigation in this area by focusing on our wn actions. The following are suggestions for what I onsider “good practice.” These are within the standard f care, but they do not purport to represent the stanard of care in the sense that they exclude other aproaches from also being appropriate. General issues uch as evaluation of patients suitable for surgery based n comorbidities are omitted.