BACKGROUND: Laparoscopic cholecystectomy is a commonly performed surgical procedure and there are instances where complications may occur intraoperatively which can go undiagnosed or unreported and the patient can present at a later time with the manifestations of those complications. This study presents a case series comprising three instances of \"ghost complications\" following laparoscopic cholecystectomy, emphasizing the utmost significance of careful follow-up care and efficient communication to promptly recognize and manage any complications arising after the surgery.
METHODS: Three cases of ghost complications post-biliary surgery are presented. These complications were initially overlooked or dismissed due to factors such as atypical symptom presentation and inadequate follow-up. The cases involve retained stones leading to secondary complications, bile leak masked by postoperative symptoms, and post-cholecystectomy syndrome mistaken for unrelated conditions.
UNASSIGNED: Diagnosing ghost complications is challenging when symptoms diverge from the expected postoperative course. Meticulous clinical suspicion and interdisciplinary collaboration are crucial for accurate diagnoses and timely intervention. Effective communication between patients and surgeons is pivotal in ensuring appropriate management.
CONCLUSIONS: This study illuminates the concept of \"ghost complications\" after biliary surgery, highlighting challenges in their recognition and management. Through three distinct cases, the study underscores the significance of vigilant follow-up care, early symptom recognition, and open communication to prevent and address such complications. Transparent communication and meticulous monitoring are vital for enhancing patient outcomes and mitigating the occurrence of \"ghost complications.\"

Risk assessment is difficult yet would provide valuable data for both the surgeons and the patients in major hepatobiliary surgeries. An ideal risk calculator should improve workflow through efficient, timely, and accurate risk stratification. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator (SRC) and Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) are surgical risk stratification tools used to assess postoperative morbidity. In this study, preoperative data from 300 patients undergoing major hepatobiliary surgeries performed at a single tertiary university hospital were retrospectively collected from electronic patient records and entered into the ACS-SRC and P-POSSUM systems, and the resulting risk scores were calculated and recorded accordingly. The ACS-NSQIP-M1 (C-statistics = 0.725) and M2 (C-statistics = 0.791) models showed better morbidity discrimination ability than P-POSSUM-M1 (C-statistics = 0.672) model. The P-POSSUM-M2 (C-statistics = 0.806) model showed better differentiation success in morbidity than other models. The ACS-NSQIP-M1 (C-statistics = 0.888) and M2 (C-statistics = 0.956) models showed better mortality discrimination than P-POSSUM-M1 (C-statistics = 0.776) model. The P-POSSUM-M2 (C-statistics = 0.948) model showed better mortality differentiation success than the ACS-NSQIP-M1 and P-POSSUM-M1 models. The use of ACS-SRC and P-POSSUM calculators for major hepatobiliary surgeries offers quantitative data to assess risks for both the surgeon and the patient. Integrating these calculators into preoperative evaluation practices can enhance decision-making processes for patients. The results of the statistical analyses indicated that the P-POSSUM-M2 model for morbidity and the ACS-NSQIP-M2 model for mortality exhibited superior overall performance.

In 2023, it was 130 years since the opening of the Alexander Surgical Hospital at the Tauride Provincial Zemstvo Hospital, where many talented doctors worked. This authors present new facts about outstanding surgeon who worked in Simferopol at the turn of the 19th and 20th centuries, Alexander Fedorovich Kablukov (1857-1915). He was a founder of surgical school in the Tauride province, who first described cholecystectomy In Russian-language literature. The report covers in detail famous surgery restored thanks to pre-revolutionary sources. Excerpts from other little-known reports of surgeon related to the treatment of gallbladder and biliary diseases are also presented.
В 2023 г. исполнилось 130 лет со дня открытия Александровской хирургической образцовой лечебницы при Таврической губернской земской больнице, в которой трудились многие талантливые врачи. Данная статья раскрывает новые факты о деятельности одного из них — выдающегося хирурга, работавшего в Симферополе на рубеже XIX—XX веков, Александра Федоровича Каблукова (1857—1915), ученика Н.В. Склифосовского и Н.Н. Бетлинга, основателя хирургической школы в Таврической губернии, которому принадлежит первое печатное описание операции холецистэктомии в русскоязычной хирургической литературе. В работе подробно освещается ход знаменитой операции Каблукова, восстановленный благодаря дореволюционным источникам. Представлены и отрывки из других, доселе малоизвестных, докладов хирурга, связанных с лечением заболеваний желчного пузыря и желчевыводящих путей.

The authors present common bile duct reconstruction using the Kehr drainage.
В статье приводится клинический случай восстановления целостности холедоха с применением дренажа по Керу.

BACKGROUND: Although minimally invasive hepato-pancreato-biliary (MIS HPB) surgery can be performed with good outcomes, there are currently no standardized requirements for centers or surgeons who wish to implement MIS HPB surgery. The aim of this study was to create a consensus statement regarding safe dissemination and implementation of MIS HPB surgical programs.
METHODS: Sixteen key questions regarding safety in MIS HPB surgery were generated after a focused literature search and iterative review by three field experts. Participants for the working group were then selected using sequential purposive sampling and snowball techniques. Review of the 16 questions took place over a single 2-h meeting. The senior author facilitated the session, and a modified nominal group technique was used.
RESULTS: Twenty three surgeons were in attendance. All participants agreed or strongly agreed that formal guidelines should exist for both institutions and individual surgeons interested in implementing MIS HPB surgery and that routine monitoring and reporting of institutional and surgeon technical outcomes should be performed. Regarding volume cutoffs, most participants (91%) agreed or strongly agreed that a minimum annual institutional volume cutoff for complex MIS HPB surgery, such as major hepatectomy or pancreaticoduodenectomy, should exist. A smaller proportion (74%) agreed or strongly agreed that a minimum annual surgeon volume requirement should exist. The majority of participants agreed or strongly agreed that surgeons were responsible for defining (100%) and enforcing (78%) guidelines to ensure the overall safety of MIS HPB programs. Finally, formal MIS HPB training, minimum case volume requirements, institutional support and infrastructure, and mandatory collection of outcomes data were all recognized as important aspects of safe implementation of MIS HPB surgery.
CONCLUSIONS: Safe implementation of MIS HPB surgery requires a thoughtful process that incorporates structured training, sufficient volume and expertise, a proper institutional ecosystem, and monitoring of outcomes.

OBJECTIVE: This study aimed to present the institutional experience and algorithm for performing biliary interventions in liver transplant patients using the modified Hutson loop access (MHLA) and the impact of percutaneous endoscopy via the MHLA on these procedures.
METHODS: Over 13 years, 201 MHLA procedures were attempted on 52 patients (45 liver transplants; 24 living and 21 deceased donors) for diagnostic (e.g., cholangiography) and therapeutic (e.g., stent/drain insertion and cholangioplasty) purposes. The most common indications for MHLA were biliary strictures (60%) and bile leaks (23%). Percutaneous endoscopy was used to directly visualize the biliary-enteric anastomosis, diagnose pathology (e.g., ischemic cholangiopathy), and help in biliary hygiene (removing debris/casts/stones/stents) in 138/201 (69%) procedures. Technical success was defined as cannulating the biliary-enteric anastomosis and performing diagnostic/therapeutic procedure via the MHLA.
RESULTS: The technical success rate was 95% (190/201). The failure rate among procedures performed with and without endoscopy was 2% (3/138) versus 13% (8/63) (P = 0.0024), and the need for new transhepatic access (to aid the procedure) was 12% (16/138) versus 30% (19/63) (P = 0.001). Despite endoscopy, failure in 2% of the cases resulted from inflamed/friable anastomosis (1/3) and high-grade stricture (2/3) obstructing retrograde cannulation of biliary-enteric anastomosis. Major adverse events (bowel perforation and injury) occurred in 1% of the procedures, with no procedure-related mortality.
CONCLUSIONS: MHLA-based percutaneous biliary intervention is a safe and effective alternative to managing complications after liver transplant. Percutaneous endoscopy via the MHLA improves success rates and may reduce the need for new transhepatic access. Level of Evidence Level 4.

UNASSIGNED: Dexmedetomidine (Dex) may have anti-inflammatory properties and potentially reduce the incidence of postoperative organ injury.
UNASSIGNED: To investigate whether Dex protects pulmonary and renal function via its anti-inflammatory effects in elderly patients undergoing prolonged major hepatobiliary and pancreatic surgery.
UNASSIGNED: Between October 2019 and December 2020, this randomized controlled trial was carried out at a tertiary hospital in Chongqing, China.
UNASSIGNED: 86 patients aged 60-75 who underwent long-duration (> 4 hrs) hepatobiliary and pancreatic surgery without significant comorbidities were enrolled and randomly assigned into two groups at a 1:1 ratio.
UNASSIGNED: Patients were given either Dex or an equivalent volume of 0.9% saline (Placebo) with a loading dose of 1 μg kg-1 for 10 min, followed by 0.5 μg kg-1 hr-1 for maintenance until the end of surgery.
UNASSIGNED: The changes in serum concentrations of interleukin-6 (IL-6) and tumour necrosis factor-α (TNF-α) were primary outcomes.
UNASSIGNED: At one hour postoperatively, serum IL-6 displayed a nine-fold increase (P<0.05) in the Placebo group. Administration of Dex decreased IL-6 to 278.09 ± 45.43 pg/mL (95% CI: 187.75 to 368.43) compared to the Placebo group (P=0.019; 432.16 ± 45.43 pg/mL, 95% CI: 341.82 to 522.50). However, no significant differences in TNF-α were observed between the two groups. The incidence of postoperative acute kidney injury was twice as high in the Placebo group (9.30%) compared to the Dex group (4.65%), and the incidence of postoperative acute lung injury was 23.26% in the Dex group, lower than that in the Placebo group (30.23%), although there was no statistical significance between the two groups.
UNASSIGNED: Dex administration in elderly patients undergoing major hepatobiliary and pancreatic surgery reduces inflammation and potentially protects kidneys and lungs.
UNASSIGNED: Chinese Clinical Trials Registry, identifier: ChiCTR1900024162, on 28 June 2019.

BACKGROUND: Although surgical resection is the only curative treatment for biliary tract cancer, in some cases, the disease is diagnosed as unresectable at initial presentation. There are few reports of conversion surgery after the initial treatment for unresectable locally advanced biliary tract cancer. This study aimed to evaluate the efficacy and safety of conversion surgery in patients with initially unresectable locally advanced biliary tract cancer.
METHODS: We retrospectively collected clinical data from groups of patients in multiple centers belonging to the Japanese Society of Hepato-Biliary-Pancreatic Surgery and Korean Association of Hepato-Biliary-Pancreatic Surgery. We analyzed two groups of prognostic factors (pretreatment and surgical factors) and their relation to the treatment outcomes.
RESULTS: A total of 56 patients with initially unresectable locally advanced biliary tract cancer were enrolled in this study of which 55 (98.2%) patients received chemotherapy, and 16 (28.6%) patients received additional radiation therapy. The median time from the start of the initial treatment to resection was 6.4 months. Severe postoperative complications of Clavien-Dindo grade III or higher occurred in 34 patients (60.7%), and postoperative mortality occurred in five patients (8.9%). Postoperative histological results revealed CR in eight patients (14.3%). The median survival time from the start of the initial treatment in all 56 patients who underwent conversion surgery was 37.7 months, the 3-year survival rate was 53.9%, and the 5-year survival rate was 39.1%.
CONCLUSIONS: Conversion surgery for initially unresectable locally advanced biliary tract cancer may lead to longer survival in selected patients. However, more precise preoperative safety evaluation and careful postoperative management are required.

OBJECTIVE: To introduce percutaneous selective injection of autologous platelet-rich fibrin as a novel technique for persistent bile leakage repair and sharing the results of our preliminary experience.
METHODS: Seven patients (57.1% females; mean age 69.6 ± 8 years) with the evidence of persistent bile leak secondary to hepatobiliary surgery and ineffective treatment with percutaneous transhepatic biliary drainage were submitted to fibrin injection. Platelet-rich fibrin, a dense fibrin clot promoting tissue regeneration, was obtained from centrifuged patient\'s venous blood. Repeated percutaneous injections through a catheter tip placed in close proximity to the biliary defect were performed until complete obliteration at fistulography. Technical and clinical success were evaluated.
RESULTS: Bile leaks followed pancreaticoduodenectomy in five and major hepatectomy in two patients. Technical success defined as fibrin injection at BD site was achieved in all seven patients, and clinical success defined as a complete healing of the BD at fistulography was achieved in six patients. The median time to BD closure was 76.7 ± 40.5 days and the average procedure number was 3 ± 1 per patient. In one patient, defect persistance after four treatments required gelatin sponge injection. No major complications occurred. One case of post-procedural transitory hyperpirexia was registered.
CONCLUSIONS: In persistent biliary defects, despite prolonged biliary drainage stay, percutaneous injection of autologous platelet-rich fibrin appears as a readily available and feasible emergent technique in promoting fistulous tracts obliteration still mantaining main ducts patency.

OBJECTIVE: Pyogenic liver abscess (PLA) is a common hepatobiliary infection that has been shown to have an increasing incidence, with biliary surgery being identified as a trigger. Our aim was to investigate the clinical characteristics and treatments of PLA patients with and without a history of biliary surgery (BS).
METHODS: The study included a total of 353 patients with PLA who received treatment at our hospital between January 2014 and February 2023. These patients were categorized into two groups: the BS group (n = 91) and the non-BS group (n = 262). In the BS group, according to the anastomosis method, they were further divided into bilioenteric anastomoses group (BEA, n = 22) and non-bilioenteric anastomoses group (non-BEA, n = 69). Clinical characteristics were recorded and analyzed.
RESULTS: The percentage of PLA patients with BS history was 25.78%. The BS group exhibited elevated levels of TBIL and activated APTT abnormalities (P = 0.009 and P = 0.041, respectively). Within the BS group, the BEA subgroup had a higher prevalence of diabetes mellitus (P < 0.001) and solitary abscesses (P = 0.008) compared to the non-BEA subgroup. Escherichia coli was more frequently detected in the BS group, as evidenced by positive pus cultures (P = 0.021). The BS group exhibited reduced treatment efficacy compared to those non-BS history (P = 0.020). Intriguingly, the BS group received a higher proportion of conservative treatment (45.05% vs. 21.76%), along with reduced utilization of surgical drainage (6.59% vs. 16.41%).
CONCLUSIONS: Patients with BS history, especially those who have undergone BEA, have an increased susceptibility to PLA formation without affecting prognosis.