Search Results (13)

Background and Clinical Significance: Biliary atresia (BA) and Alagille syndrome (ALGS) represent distinct anatomic and genetic causes of neonatal cholestasis. Their overlapping clinical, biochemical, and early histological features present a formidable diagnostic challenge in early infancy, and their simultaneous coexistence is exceedingly rare. This report documents a unique case of dual diagnosis to highlight the associated diagnostic pitfalls and implications for surgical management. Case Presentation: We present the case of a Taiwanese male neonate who manifested prolonged jaundice and acholic stools. Preoperative imaging and intraoperative cholangiography confirmed biliary atresia, for which the patient underwent a Kasai portoenterostomy. The patient subsequently exhibited an atypical postoperative course characterized by persistent hyperbilirubinemia and intractable pruritus. This atypical trajectory prompted an extensive, multisystem evaluation and molecular genetic analysis, revealing a concurrent genetic diagnosis of Alagille syndrome. To our knowledge, this dual diagnosis is rarely reported in the literature, which creates a significant challenge in determining surgical candidacy and predicting long-term liver health outcomes. Discussions: Early differentiation is complicated by the fact that some ALGS patients can initially mimic BA. Beyond its exceptional rarity, this case holds profound clinical significance for the evaluation of neonatal cholestasis, serving as a stark reminder of the risks of “diagnostic premature closure.” In diagnostically challenging cases of neonatal cholestasis, intraoperative biliary exploration remains the gold standard for the timely diagnosis of BA. Genetic testing should be considered an adjunctive tool when clinical and histological findings are inconclusive. Conclusions: This case highlights a critical clinical caveat in neonatal cholestasis: while a confirmed diagnosis of anatomical BA typically stands alone as a solitary pathology, clinicians should remain mindful of the remote possibility of a concurrent genetic etiology like ALGS in highly atypical presentations. Persistently unexpected postoperative jaundice or the accumulation of multisystem anomalies should prompt an expansion of the differential diagnosis. Recognizing this rare coexistence is crucial for effective multidisciplinary management, informed surgical decision-making, and accurate genetic counseling. Full article

Laparoscopic cholecystectomy is now established as the worldwide gold standard for the treatment of benign gallbladder disease. Despite technical advancements, bile duct injury (BDI) remains a major concern, especially in patients with obesity. It is well known that in patients with a Body Mass Index (BMI) ≥ 30 kg/m², identification of Calot’s triangle and the achievement of the Critical View of Safety (CVS) during laparoscopic cholecystectomy (LC) are made more challenging due to excessive visceral adiposity and concomitant hepatic steatosis reducing the workspace. Near-Infrared Fluorescence Cholangiography (NIRF-C) with Indocyanine Green (ICG) has emerged as an innovative, safe and effective technique to visualize the biliary anatomy and minimize the risk of iatrogenic BDI. However, its specific benefit in patients with obesity remains under-discussed compared to the general population. The main aim of this narrative review is to evaluate whether the intraoperative use of ICG in patients with obesity may reduce operative times and the risk of BDI. A focused review of the literature is performed on articles from 2010 to 2025 published on PubMed, Scopus and Web of Science. The application of ICG fluorescence in LC for patients with obesity represents a tangible clinical advantage, not only for anatomical identification and significant improvement of procedural efficiency, but also for the reduction in operative time. Full article

Background: Kartagener syndrome (KS) is a rare subset of primary ciliary dyskinesia characterized by the triad of situs viscerum inversus (SVI), chronic sinusitis, and bronchiectasis. Laparoscopic cholecystectomy (LC) in patients with SVI is technically demanding because of mirror-image anatomy, while evidence supporting the use of indocyanine green (ICG) fluorescence in this setting is scarce. Case Presentation: We report the case of a 25-year-old woman with KS and SVI totalis who underwent elective LC for symptomatic cholelithiasis. The procedure was performed using a mirror American approach with four trocars and near-infrared ICG fluorescence cholangiography. ICG enabled real-time visualization of biliary anatomy and facilitated intraoperative orientation. The procedure was completed laparoscopically without intraoperative or postoperative complications, and the postoperative course was uneventful. Methods: A non-systematic narrative review of the literature was conducted to identify reported cases of LC in patients with SVI, including cases associated with KS. Studies published between 1991 and 2025 were retrieved from PubMed, Web of Science, Scopus, and Embase. Data were descriptively summarized, focusing on surgical technique, trocar placement, and reported use of ICG fluorescence. Results: A total of 143 articles were included. Most cases involved isolated SVI, while KS was reported only in a minority of patients. The mirror American technique and four-trocar configuration were the most frequently adopted approaches. Only three cases, including the present report, described the use of ICG fluorescence during LC in patients with SVI or KS. Conclusions: LC in patients with SVI is feasible but technically demanding. ICG fluorescence may assist intraoperative biliary orientation in complex anatomical settings; however, current evidence is extremely limited and should be considered hypothesis-generating only. Full article

Background and Objectives: Bile duct injury is a relatively rare, but critical complication of laparoscopic cholecystectomy and is most commonly attributed to misinterpretation of biliary anatomy. Intraoperative biliary imaging may enhance anatomical recognition and reduce operative uncertainty, yet the optimal imaging modality remains debated. This study aimed to compare conventional intraoperative X-ray cholangiography with two fluorescence-based techniques—intravenous and intracholecystic indocyanine green fluorescence cholangiography—with respect to biliary visualization, perioperative outcomes, and surgeon satisfaction during elective laparoscopic cholecystectomy. Materials and Methods: This prospective, single-center, single-blind randomized controlled trial included 240 adult patients scheduled for elective laparoscopic cholecystectomy between June 2021 and December 2022. Participants were randomized equally to standard intraoperative cholangiography, intravenous indocyanine green fluorescence cholangiography, or intracholecystic indocyanine green fluorescence cholangiography. The primary outcome was successful visualization of predefined extrahepatic biliary landmarks, including the critical junction. Secondary outcomes included cholangiography duration, perioperative complications, postoperative inflammatory markers, and surgeon satisfaction assessed using a five-point Likert scale. This study was registered at ClinicalTrials.gov (NCT04908826). Results: Visualization rates of the critical junction and major extrahepatic bile ducts were comparable among three groups, with no statistically significant differences observed. Both fluorescence-based techniques achieved a 100% technical success rate, whereas standard cholangiography failed in a small proportion of cases. Cholangiography duration was significantly shorter in the fluorescence groups compared with standard cholangiography (p < 0.001). Surgeon satisfaction scores were significantly higher for both fluorescence approaches, with a slight preference for intravenous administration. Perioperative complication rates and postoperative inflammatory markers were com-parable among groups. Conclusions: Intravenous and intracholecystic indocyanine green fluorescence cholangiography are non-inferior to conventional intraoperative cholangiography for biliary anatomy visualization and offer advantages in procedural efficiency and surgeon satisfaction. Fluorescence-based imaging represents a safe and effective alternative for intraoperative biliary mapping during elective laparoscopic cholecystectomy. Full article

Despite significant advancements in bioimaging technology, only a limited number of fluorophores are currently approved for clinical applications. Indocyanine green (ICG) is the first FDA-approved near-infrared (NIR) fluorophore and has significantly advanced clinical interventions over the past three decades. However, its single-channel imaging at 800 nm emission is often insufficient for capturing comprehensive diagnostic information during surgery. In this study, we evaluate indocyanine blue (ICB), an ICG analog with a shorter polymethine bridge, as a promising candidate for multi-channel NIR imaging. ICB demonstrated peak absorption and emission approximately 100 nm shorter than ICG in aqueous solutions, placing it within the 700 nm range of the NIR window. Furthermore, ICB exhibited favorable solubility and optical properties in aqueous environments, supporting its potential for in vivo imaging applications. Notably, ICB shows rapid systemic clearance, likely due to its lower molecular weight, which facilitates clear visualization in angiography, cholangiography, and lymph node mapping with minimal background interference. Additionally, dual-channel imaging of tumors and lymph nodes was achieved using a tumor-targeting fluorophore in conjunction with ICB, illustrating the potential for enhanced intraoperative guidance. ICB emitting at 700 nm, therefore, can be useful in NIR imaging, broadening the possibilities for improved diagnostic accuracy and therapeutic outcomes in clinical settings. Full article

Background: The gold standard treatment of acute cholecystitis is early laparoscopic cholecystectomy (LC), as indicated in the Tokyo Guidelines (TG). However, the definition of “early” is still unclear. In 2013, TG suggested surgical intervention within 72 h from the onset of the symptoms; however, according to the 2018 revision, LC must be performed as soon as possible, regardless of symptom onset. Therefore, the optimal timing for surgery is still debated. In order to avoid any complications, surgeons need to know all the surgical strategies for safety in case of a difficult cholecystectomy. Methods and Materials: Starting from January 2023 at Cittiglio Hospital (Italy), the following strategies were implemented: LC within 72 h from the onset of symptoms, systematic intraoperative use of indocyanine green fluorescence cholangiography, systematic identification of the Critical View of Safety (CVS), and subtotal cholecystectomy when the CVS was impossible to identify. We retrospectively analyzed a cohort of patients who underwent LC in our surgical department, subdividing them into two groups: Group 1 (G1) included patients operated on in 2022, and Group 2 (G2) included patients operated on in 2023. End points were length of stay and in-hospital postoperative complications, with particular interest in biliary duct injury. Results: Overall, 210 LC have been performed (97 in G1 and 113 in G2). After the introduction of the new safety strategy, the median length of stay (3 days in G1 vs. 2 in G2), BDI rate (2 in G1 vs. 0 in G2), and conversion rate to open procedure (5 in G1 vs. 1 in G2) were decreased. Conclusions: Our data are promising, highlighting that LC with the standardization of new safety strategies, especially in case of acute cholecystitis, immediately improves surgical outcomes in terms of length of stay and complications. Full article

Background: For patients with obstructive jaundice and who are indicated for pancreaticoduodenectomy (PD) or biliary intervention, either endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography and drainage (PTCD) may be indicated preoperatively. However, the possibility of procedure-related postoperative biliary tract infection (BTI) should be a concern. We tried to evaluate the impact of ERCP and PTCD on postoperative BTI. Methods: Patients diagnosed from June 2013 to March 2022 with periampullary lesions and with PD indicated were enrolled in this cohort. Patients without intraoperative bile culture and non-neoplastic lesions were excluded. Clinical information, including demographic and laboratory data, pathologic diagnosis, results of microbiologic tests, and relevant infectious outcomes, was extracted from medical records for analysis. Results: One-hundred-and-sixty-four patients from the cohort (164/689) underwent preoperative biliary intervention, either ERCP (n = 125) or PTCD (n = 39). The positive yield of intraoperative biliary culture was significantly higher in patients who underwent ERCP than in PTCD (90.4% vs. 41.0%, p < 0.001). Although there was no significance, a trend of higher postoperative BTI (13.8% vs. 2.7%) and BTI-related septic shock (5 vs. 0, 4.0% vs. 0%) in the ERCP group was noticed. While the risk factors for postoperative BTI have not been confirmed, a trend suggesting a higher incidence of BTI associated with ERCP procedures was observed, with a borderline p-value (p = 0.05, regarding ERCP biopsy). Conclusions: ERCP in patients undergoing PD increases the positive yield of intraoperative biliary culture. PTCD may be the favorable option if preoperative biliary intervention is indicated. Full article

Background: Intraoperative biliary anatomy recognition is crucial for safety during laparoscopic cholecystectomy, since iatrogenic bile duct injuries represent a fatal complication, occurring in up to 0.9% of patients. Indocyanine green fluorescence cholangiography (ICG-FC) is a safe and cost-effective procedure for achieving a critical view of safety and recognizing early biliary injuries. The aim of this study is to compare the perioperative outcomes, usefulness and safety of standard intraoperative cholangiography (IOC) with ICG-FC with intravenous ICG. Methods: Between 1 June 2021 and 31 December 2022, 160 patients undergoing elective LC were randomized into two equal groups: Group A (standard IOC) and group B (ICG-FC with intravenous ICG). Results: No significant difference was found between the two groups regarding demographics, surgery indication or surgery duration. No significant difference was found regarding the visualization of critical biliary structures. However, the surgeon satisfaction and cholangiography duration presented significant differences in favor of ICG-FC. Regarding the inflammatory response, a significant difference between the two groups was found only in postoperative WBC levels. Hepatic and renal function test results were not significantly different between the two groups on the first postoperative day, except for direct bilirubin. No statistically significant difference was noted regarding 30-day postoperative complications, while none of the complications noted included bile duct injury events. Conclusions: ICG-FC presents equivalent results to IOC regarding extrahepatic biliary visualization and postoperative complications. However, more studies need to be performed in order to standardize the optimal dose, timing and mode of administration. Full article

Despite significant advances in hepatobiliary surgery, biliary injury and leakage remain typical postoperative complications. Thus, a precise depiction of the intrahepatic biliary anatomy and anatomical variant is crucial in preoperative evaluation. This study aimed to evaluate the precision of 2D and 3D magnetic resonance cholangiopancreatography (MRCP) in exact mapping of intrahepatic biliary anatomy and its variants anatomically in subjects with normal liver using intraoperative cholangiography (IOC) as a reference standard. Thirty-five subjects with normal liver activity were imaged via IOC and 3D MRCP. The findings were compared and statistically analyzed. Type I was observed in 23 subjects using IOC and 22 using MRCP. Type II was evident in 4 subjects via IOC and 6 via MRCP. Type III was observed equally by both modalities (4 subjects). Both modalities observed type IV in 3 subjects. The unclassified type was observed in a single subject via IOC and was missed in 3D MRCP. Accurate detection by MRCP of intrahepatic biliary anatomy and its anatomical variants was made in 33 subjects out of 35, with an accuracy of 94.3% and a sensitivity of 100%. In the remaining two subjects, MRCP results provided a false-positive pattern of trifurcation. MRCP competently maps the standard biliary anatomy. Full article

The early diagnosis of biliary atresia (BA) in cholestatic infants is critical to the success of the treatment. Intraoperative cholangiography (IOC), an invasive imaging technique, is the current strategy for the diagnosis of BA. Ultrasonography has advanced over recent years and emerging techniques such as shear wave elastography (SWE) have the potential to improve BA diagnosis. This review sought to evaluate the diagnostic efficacy of advanced ultrasonography techniques in the diagnosis of BA. Six databases (CINAHL, Medline, PubMed, Google Scholar, Web of Science (core collection), and Embase) were searched for studies assessing the diagnostic performance of advanced ultrasonography techniques in differentiating BA from non-BA causes of infantile cholestasis. The meta-analysis was performed using Meta-DiSc 1.4 and Comprehensive Meta-analysis v3 software. Quality Assessment of Diagnostic Accuracy Studies tool version 2 (QUADAS-2) assessed the risk of bias. Fifteen studies consisting of 2185 patients (BA = 1105; non-BA = 1080) met the inclusion criteria. SWE was the only advanced ultrasonography technique reported and had a good pooled diagnostic performance (sensitivity = 83%; specificity = 77%; AUC = 0.896). Liver stiffness indicators were significantly higher in BA compared to non-BA patients (p < 0.000). SWE could be a useful tool in differentiating BA from non-BA causes of infantile cholestasis. Future studies to assess the utility of other advanced ultrasonography techniques are recommended. Full article

In the pediatric surgical environment, we can enrich our knowledge and improve our skills through interdisciplinary knowledge transfer in exchange with other surgical or even non-surgical disciplines. To demonstrate this, we present in this article three patient cases of method transfer enabling new techniques in minimally invasive pediatric surgery. 1. The somewhat modified application of the AeroStat rigid tip laparoscopic cholangiography catheter during the single-step laparoscopic cholecystectomy facilitates the safe intraoperative cholangiography with common bile duct flushing. 2. A magnetic rod is used during laparoscopic enterotomy to locate and retrieve ingested magnets. 3. Using a patient-specific MRI 3D model representing a syndromic high anorectal malformation improves surgical planning and parental education. Full article

(1) Background: Fluorescence cholangiography has been proposed as a method for improving the visualization and identification of extrahepatic biliary anatomy in order to possibly reduce injuries and related complications. The most common method of indocyanine green (ICG) administration is the intravenous route, whereas evidence on direct ICG injection into the gallbladder is still quite limited. We aimed to compare the two different methods of ICG administration in terms of the visualization of extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC), analyzing differences in the time of visualization, as well as the efficacy, advantages, and disadvantages of both modalities. (2) Methods: A total of 35 consecutive adult patients affected by acute or chronic gallbladder disease were enrolled in this prospective case–control study. Seventeen patients underwent LC with direct gallbladder ICG injection (IC-ICG) and eighteen subjects received intravenous ICG administration (IV-ICG). (3) Results: The groups were comparable with regard to their demographic and perioperative characteristics. The IV-ICG group had a significantly shorter overall operative time compared to the IC-ICG group (p = 0.017). IV-ICG was better at delineating the duodenum and the common hepatic duct compared to the IC-ICG method (p = 0.009 and p = 0.041, respectively). The cystic duct could be delineated pre-dissection in 76.5% and 66.7% of cases in the IC-ICG and IV-ICG group, respectively, and this increased to 88.2% and 83.3% after dissection. The common bile duct could be highlighted in 76.5% and 77.8% of cases in the IC-ICG and IV-ICG group, respectively. Liver fluorescence was present in one case in the IC-ICG group and in all cases after IV-ICG administration (5.8% versus 100%; p < 0.0001). (4) Conclusions: The present study demonstrates how ICG-fluorescence cholangiography can be helpful in identifying the extrahepatic biliary anatomy during dissection of Calot’s triangle in both administration methods. In comparison with intravenous ICG injection, the intracholecystic ICG route could provide a better signal-to-background ratio by avoiding hepatic fluorescence, thus increasing the bile duct-to-liver contrast. Full article

Annular pancreas is a rare congenital abnormality. This entity can rarely be symptomatic. Patients can present with gastrointestinal obstruction or acute pancreatitis. We report a case with a rich iconography, of an annular pancreas discovered intraoperatively. A 46- year-old woman was operated with the diagnosis of acute cholecystitis with common bile duct stones. At operation, a strip of pancreatic tissue (2 cm) completely encircled the second duodenum. Open cholecytectomy with choledocotomy and stones extractionwas done. Postoperatively, she developed an acute pancreatitis. The post-operative cholangiography showed the annular duct surrounding the second duodenum. Annular pancreas is rare. Symptoms may occur in newborn children. In adults, annular pancreas discovering is radiological or intra operatively. Full article