Impact of open hepatectomy on postoperative bile leakage in patients with biliary tract cancer

BACKGROUND Bile leakage is a common and serious complication of open hepatectomy for the treatment of biliary tract cancer.AIM To evaluate the incidence,risk factors,and management of bile leakage after open hepatectomy in patients with biliary tract cancer.METHODS We retrospectively analyzed 120 patients who underwent open hepatectomy for biliary tract cancer from February 2018 to February 2023.Bile leak was defined as bile drainage from the surgical site or drain or the presence of a biloma on imaging.The incidence,severity,timing,location,and treatment of the bile leaks were recorded.The risk factors for bile leakage were analyzed using univariate and multivariate logistic regression analyses.RESULTS The incidence of bile leak was 16.7%(20/120),and most cases were grade A(75%,15/20)according to the International Study Group of Liver Surgery classification.The median time of onset was 5 d(range,1-14 d),and the median duration was 7 d(range,2-28 d).The most common location of bile leakage was the cut surface of the liver(70%,14/20),followed by the anastomosis site(25%,5/20)and the cystic duct stump(5%,1/20).Most bile leaks were treated conservatively with drainage,antibiotics,and nutritional support(85%,17/20),whereas some required endoscopic retrograde cholangiopancreatography with stenting(10%,2/20)or percutaneous transhepatic cholangiography with drainage(5%,1/20).Risk factors for bile leakage include male sex,hepatocellular carcinoma,major hepatectomy,blood loss,and blood transfusion.CONCLUSION Bile leakage is a frequent complication of open hepatectomy for biliary tract cancer.However,most cases are mild and can be conservatively managed.Male sex,hepatocellular carcinoma,major hepatectomy,blood loss,and blood transfusion were associated with an increased risk of bile leak.

Pedicled greater omentum flap for preventing bile leak in liver transplantation patients with poor biliary tract conditions

BACKGROUND: Bile leak remains a main complication in liver transplantation patients with poor biliary tract conditions, mainly caused by an insufficient blood supply or dysplasia of the biliary tract. Although Roux-en-Y modus operandi can be adopted, the risk of other complications of the biliary tract such as infection increases. Using pedicled greater omentum flaps to wrap the anastomotic stoma, which increases the biliary tract blood supply, may reduce the incidence of bile leak. METHODS: Fourteen patients undergoing piggy-back liver transplantation and having poor biliary tract conditions were treated with pedicled greater omentum flaps to wrap the anastomotic stoma of the biliary tract. Their clinical data were analyzed retrospectively. RESULTS: Of the 14 patients, only one (7.1%) had a mild bile leak on the 8th day post-operation and fully recovered after symptomatic treatment. The other patients had no biliary complications. CONCLUSIONS: Using pedicled greater omentum flaps to wrap the anastomotic stoma of the biliary tract is an effective way to prevent bile leak in liver transplantation patients, especially those with poor biliary tract conditions. However, experience with this surgical technique still needs to be further explored.

Bile leakage after loop closure vs clip closure of the cystic duct during laparoscopic cholecystectomy:A retrospective analysis of a prospective cohort

BACKGROUND Laparoscopic cholecystectomy(LC)is one of the most frequently performed surgical procedures.Cystic stump leakage is an underestimated,potentially life threatening complication that occurs in 1%-6%of the patients.With a secure cystic duct occlusion technique during LC,bile leakage becomes a preventable complication.AIM To investigate the effect of polydioxanone(PDS)loop closure of the cystic duct on bile leakage rate in LC patients.METHODS In this retrospective analysis of a prospective cohort,the effect of PDS loop closure of the cystic duct on bile leakage complication was compared to patients with conventional clip closure.Logistic regression analysis was used to develop a risk score to identify bile leakage risk.Leakage rate was assessed for categories of patients with increasing levels of bile leakage risk.RESULTS Of the 4359 patients who underwent LC,136(3%)underwent cystic duct closure by a PDS loop.Preoperatively,loop closure patients had significantly more complicated biliary disease compared to the clipped closure patients.In the loop closure cohort,zero(0%)bile leakage occurred compared to 59 of 4223(1.4%)clip closure patients.For patients at increased bile leakage risk(risk score≥1)rates were 1.6%and up to 13%(4/30)for clip closure patients with a risk score≥4.This risk increase paralleled a stepwise increase of actual bile leakage complication for clip closure patients,which was not observed for loop closure patients.CONCLUSION Cystic duct closure with a PDS loop during LC may reduce bile leakage in patients at increased risk for bile leakage.

Successful outcome of sphincterotomy and 7 French pigtail stent insertion in the management of post-cholecystectomy bile leaks

BACKGROUND:Endoscopic retrograde cholangiopancrea-tography(ERCP)is widely used to manage post-cholecystectomy bile leaks.However,the best endoscopic intervention remains controversial.We investigated the success of a 7 French double pigtail stent following sphincterotomy in the management of such bile leaks. METHODS:Between July 1998 and June 2008,48 patients were referred for ERCP for presumed post-cholecystectomy bile leaks.Leaks were confirmed at ERCP and managed by a combination of sphincterotomy and stent insertion unless contraindicated. RESULTS:Bile duct cannulation was successful in 44(91.7%)patients.A leak of the cystic duct was demonstrated in 19(43.2%)patients,the duct of Luschka in 11(25.0%),and the common hepatic duct in 5 (11.4%).Complete transection of the common bile duct occurred in 4 patients.The remaining patients had no cholangiographic evidence of a leak.Sphincterotomy was performed in 34 patients.A 7 French double pigtail plastic stent was placed in all 35 patients with cholangiographic evidence of a bile leak.No bile leaks were demonstrated at a follow-up of 8-16 weeks and all stents were removed successfully. CONCLUSION:The combination of sphincterotomy and insertion of a 7 French double pigtail stent results in excellent outcomes in the management of post-cholecystectomy bile leaks.

ERCP for the treatment of bile leak after partial hepatectomy and fenestration for symptomatic polycystic liver disease

AIM: To describe endoscopic treatment of bile leaks in these patients and to identify risk factors in these patients which can predict the development of bile leaks. METHODS: Retrospective case-control study examining consecutive patients who underwent partial hepatectomy for polycystic liver disease (PLD) and developed a postoperative bile leak managed endoscopically over a ten year period. Each case was matched with two controls with PLD who did not develop a postoperative bile leak. RESULTS: Ten cases underwent partial hepatectomy with fenestration for symptoms including abdominal distention, pain and nausea. Endoscopic retrograde cholangiopancreatography (ERCP) showed anatomic abnormalities in 1 case. A biliary sphincterotomy was performed in 4 cases. A plastic biliary stent was placed with the proximal end at the site of the leak in 9 cases; in 1 case two stents were placed. The overall success rate of ERCP to manage the leak was 90%. There were no significant differences in age, gender, comorbidities, duration of symptoms, history of previous surgery or type of surgery performed between cases and controls. CONCLUSION: ERCP with stent placement is safe and effective for management of post-hepatectomy bile leak in patients with PLD.

Evaluation of fully covered self-expanding metal stents in benign biliary strictures and bile leaks

AIM: To investigate the use of fully covered metal stents in benign biliary strictures (BBS) and bile leaks. METHODS: We studied 17 patients, at Harbor-UCLA Medical center (Los Angeles), with BBS (n=12) and bile leaks (n=5) from July 2007 to February 2012 that had received placement of fully covered self-expanding metal stents (FCSEMs). Fourteen patients had endoscopic placement of VIABIL (Conmed, Utica, New York, United States) stents and three had Wallflex (Boston Scientific, Mass) stents. FCSEMS were 8 mm or 10 mm in diameter and 4 cm to 10 cm in length. Patients were followed at regular intervals to evaluate for symptoms and liver function tests. FCSEMS were removed after 4 or more weeks. Resolution of BBS and leak was documented cholangiographically following stent removal. Stent patency can be defined as adequate bile and contrast flow from the stent and into the ampulla during endoscopic retrograde cholangiopancreatography (ERCP) without clinical signs and/or symptoms of biliary obstruction. Criterion for bile leak resolution at ERCP is defined as absence of contrast extravasation from the common bile duct, cystic duct remanent, or gall blad-der fossa. Rate of complications such as migration, and instent occlusion were recorded. Failure of endoscopic therapy was defined as persistent biliary stenosis or continuous biliary leakage after 12 mo of stent placement. RESULTS: All 17 patients underwent successful FC- SEMS placement and removal. Etiologies of BBS included: cholecystectomies (n=8), cholelithiasis (n=2), hepatic artery compression (n=1), pancreatitis (n=2), and Whipple procedure (n=1). All bile leaks occurred following cholecystectomy. The anatomic location of BBS varied: distal common bile duct (n=7), common hepatic duct (n=1), hepaticojejunal anastomosis (n=2), right intrahepatic duct (n=1), and choledochoduo-denal anastomatic junction (n=1). All bile leaks were found to be at the cystic duct. Twelve of 17 patients had failed prior stent placement or exchange. Resolution of the biliary strictures and bile leaks was achieved in 16 of 17 patients (94%). The overall median stent time was 63 d (range 27-251 d). The median stent time for the BBS group and bile leak group was 62 ± 58 d (range 27-199 d) and 92 ± 81 d (range 48-251 d), respectively. All 17 patients underwent successful FCSEMS removal. Long term follow-up was obtained for a median of 575 d (range 28-1435 d). Complications occurred in 5 of 17 patients (29%) and included: migration (n=2), stent clogging (n=1), cholangitis (n=1), and sepsis with hepatic abscess (n=1). CONCLUSION: Placement of fully covered self-expanding metal stents may be used in the management of benign biliary strictures and bile leaks with a low rate of complications.

Role of ablation therapy in conjunction with surgical resection for neuroendocrine tumors involving the liver

BACKGROUND Resection of hepatic metastasis from neuroendocrine tumors(NETs)improves quality of life and prolongs 5-year survival.Ablation can be utilized with surgery to achieve complete resection.Although several studies report long-term out-comes for patients undergoing ablation,none have explored perioperative effects of ablation in patients with metastatic NETs.AIM To determine if intra-operative ablation during hepatectomy increases risk of ad-verse outcomes such as surgical site infections(SSIs),bleeding,and bile leak.METHODS A retrospective analysis of the hepatectomy National Surgical Quality Impro-vement Program database from 2015-2019 was performed to determine the odds of SSIs,bile leaks,or bleeding in patients undergoing intraoperative ablation when compared to hepatectomy alone.RESULTS Of the 966 patients included in the study,298(30.9%)underwent ablation during hepatectomy.There were 78(11.7%)patients with SSIs in the hepatectomy alone group and 39(13.1%)patients with a SSIs in the hepatectomy with ablation group.Bile leak occurred in 41(6.2%)and 14(4.8%)patients in the two groups,respec-tively;bleeding occurred in 117(17.5%)and 33(11.1%),respectively.After con-trolling for confounding variables,ablation did not increase risk of SSI(P=0.63),bile leak(P=0.34)or bleeding(P=0.07)when compared to patients undergoing resection alone on multivariate analysis.CONCLUSION Intraoperative ablation with hepatic resection for NETs is safe in the perioperative period without significant increased risk of infection,bleeding,or bile leak.Surgeons should utilize this modality when appropriate to a-chieve optimal disease control and outcomes.

Classification of iatrogenic bile duct injury

BACKGROUND: Iatrogenic bile duct injury continues to be an important clinical problem, resulting in serious morbidity, and occasional mortality, to patients. The ease of management, operative risk, and outcome of bile duct injuries vary considerably, and are highly dependent on the type of injury and its location. This article reviews the various classification systems of bile duct injury. DATA SOURCES: A Medline, PubMed database search was performed to identify relevant articles using the keywords 'bile duct injury', 'cholecystectomy', and 'classification'. Additional papers were identified by a manual search of the references from the key articles. RESULTS: Traditionally, biliary injuries have been classified using the Bismuth's classification. This classification, which originated from the era of open surgery, is intended to help the surgeons to choose the appropriate technique for the repair, and it has a good correlation with the final outcome after surgical repair. However, the Bismuth's classification does not encompass the whole spectrum of injuries that are possible. Bile duct injury during laparoscopic cholecystectomy tends to be more severe than those with open cholecystectomy. Strasberg's classification made Bismuth's classification much more comprehensive by including various other types of extrahepatic bile duct injuries. Our group, Bergman et al, Neuhaus et al, Csendes et al, and Stewart et al have also proposed other classification systems to complement the Bismuth's classification. CONCLUSIONS: None of the classification system is universally accepted as each has its own limitation. Hopefully, a universally accepted comprehensive classification system will be published in the near future.

Outcomes of laparoscopic bile duct exploration for choledocholithiasis with small common bile duct

BACKGROUND Laparoscopic cholecystectomy(LC)combined with laparoscopic common bile duct(CBD)exploration(LCBDE)is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm.However,for patients with small CBD(CBD diameter≤8 mm),endoscopic sphincterotomy remains the preferred treatment at present,but it also has some drawbacks associated with a series of complications,such as pancreatitis,hemorrhage,cholangitis,and duodenal perforation.To date,few studies have been reported that support the feasibility and safety of LCBDE for choledocholithiasis with small CBD.AIM To investigate the feasibility and safety of LCBDE for choledocholithiasis with small CBD.METHODS A total of 257 patients without acute cholangitis who underwent LC+LCBDE for cholecystolithiasis from January 2013 to December 2018 in one institution were reviewed.The clinical data were retrospectively collected and analyzed.According to whether the diameter of CBD was larger than 8 mm,257 patients were divided into large CBD group(n=146)and small CBD group(n=111).Propensity score matching(1:1)was performed to adjust for clinical differences.The demographics,intraoperative data,short-term outcomes,and long-term follow-up outcomes for the patients were recorded and compared.RESULTS In total,257 patients who underwent successful LC+LCBDE were enrolled in the study,146 had large CBD and 111 had small CBD.The median follow-up period was 39(14-86)mo.For small CBD patients,the median CBD diameter was 0.6 cm(0.2-2.0 cm),the mean operating time was 107.2±28.3 min,and the postoperative bile leak rate,rate of residual CBD stones(CBDS),CBDS recurrence rate,and CBD stenosis rate were 5.41%(6/111),3.60%(4/111),1.80%(2/111),and 0%(0/111),respectively;the mean postoperative hospital stay was 7.4±3.6 d.For large CBD patients,the median common bile duct diameter was 1.0 cm(0.3-3.0 cm),the mean operating time was 115.7±32.0 min,and the postoperative bile leak rate,rate of residual CBDS,CBDS recurrence rate,and CBD stenosis rate were 5.41%(9/146),1.37%(2/146),6.85%(10/146),and 0%(0/146),respectively;the mean postoperative hospital stay was 7.7±2.7 d.After propensity score matching,184 patients remained,and all preoperative covariates except diameter of CBD stones were balanced.Postoperative bile leak occurred in 11 patients overall(5.98%),and no difference was found between the small CBD group(4.35%,4/92)and the large CBD group(7.61%,7/92).The incidence of CBDS recurrence did not differ significantly between the small CBD group(2.17%,2/92)and the large CBD group(6.52%,6/92).CONCLUSION LC+LCBDE is safe and feasible for choledocholithiasis patients with small CBD and did not increase the postoperative bile leak rate compared with choledocholithiasis patients with large CBD.

Endoscopic diagnosis and treatment of biliary leak in patients following liver transplantation:a prospective clinical study

BACKGROUND: Orthotopic liver transplantation has been widely used in patients with end-stage liver disease within the last two decades. However, the prevalence of biliary complications after liver transplantation remains high. The most common short-term biliary complication may be biliary leak. So, we examined 13 patients with biliary leak after liver transplantation, attempting to evaluate the role of endoscopic diagnosis and treatment of biliary leak and the incidence of bile duct stricture after healing of the leak. METHODS: Six cases of T-tube leak and seven cases of anastomosis leak complicating liver transplantation were enrolled in this prospective study. Six patients were treated by endoscopic plastic stent placement, two by nasobiliary catheter drainage, two by papillosphincterotomy, and three by nasobiliary catheter drainage combined with plastic stent placement. Some patients received growth hormone treatment. RESULTS: The bile leak resolution time was 10-35 days in 10 patients with complete documentation. The median time of leak resolution was 15.3 days. Four cases of anastomosis stricture, three cases of common hepatic duct and one case of multiple bile duct stenosis were detected by follow-up nasobiliary catheter cholangiography or endoscopic retrograde cholangiopancreatography. CONCLUSIONS: Endoscopic nasobiliary catheter or plastic stent placement is a safe and effective treatment for bile duct stricture occurring after bile leak resolution in most liver transplantation patients. Nasobiliary catheter combined with plastic stent placement may be the best choice for treating bile leak, because, theoretically, it may prevent the serious condition resulting from accidental nasobiliary catheter dislocation, and it may have prophylactic effects on upcoming bile duct stricture, although this should be further confirmed.

腹腔镜胆囊切除术后胆漏的临床分析

目的 :探讨腹腔镜胆囊切除术后胆漏的原因及合理治疗方法。方法 :回顾分析 2 5 432例腹腔镜胆囊切除术后并发 32例胆漏的临床资料。结果 :4例行开腹手术治疗 ;13例单纯引流 ,其中 3例中转开腹 ;腹腔镜探查 15例 ,13例在腹腔镜下完成治疗 ,2例中转开腹手术治疗。结论 :腹腔镜胆囊切除术置肝下引流管治疗胆漏有很高的应用价值 ,B超引导置管治疗仅适于迟发包裹性胆漏。

超声刀对胆囊管钳闭作用的实验研究

目的用超声刀对猪胆囊管进行凝固、切割,观察有无残端胆漏的发生,进一步探讨超声刀在肝胆外科中的应用。方法将10头20kg左右的家猪分成A和B两组,A组于腹腔镜下用超声刀在Level3档3s凝固,切断胆囊管,B组用超声刀同样条件下切断胆囊管后,再在胆总管远端钳夹钛夹一道。手术中切除胆囊,观察10min,手术后3d开腹观察胆囊管残端有无胆漏发生,并取胆囊管残断组织作病理学检查。结果A组在手术中及手术后3d胆囊管残端均无胆漏发生。B组术后第3天有1例发生胆囊管残端漏。胆囊管残端组织病理学检查两组组织均炎症细胞浸润明显,管壁血管栓塞,管腔内有坏死和凝固物,但仍有腔隙存在。1例胆漏的残端组织也有炎症细胞浸润,腔内无坏死和凝固物,腔隙明显。结论超声刀对较细的胆管有切断和钳闭作用,而对粗的胆管及有胆道压力增高情况的病例有发生胆漏的可能。

腹腔镜下置管术治疗胆漏临床评价

目的 :探讨胆漏的原因及防治策略。方法 :回顾分析 32例胆漏患者的病历资料。结果 :2 8例采用腹腔镜下置管引流 ,4例因胆管损伤行剖腹探查处理。全组无死亡病例。结论 :胆漏应及早发现、及时处理 。

肝移植术后胆道并发症的内镜下诊治

目的初步探讨内镜在肝移植术后胆道并发症诊治中的临床应用价值。方法35例肝移植术后出现胆道并发症患者,共行ERCP124次,其中行ERCP次数最少为1次,最多为17次,平均为3.54次。根据患者的情况进行扩张、EST、取石、鼻胆管引流、内支架置入等治疗。结果13例为单纯的胆道吻合口狭窄,经胆道扩张后胆道梗阻症状解除,其中1例术后4个月因肝癌远处转移死亡;3例为单纯吻合口胆瘘,经EST及支撑管,胆瘘愈合;7例胆道狭窄合并胆瘘,经EST及胆道扩张后放入支撑管,胆瘘愈合;12例胆道狭窄合并狭窄上端胆总管及肝内胆管结石,经胆道扩张后取出部分结石。所有患者经治疗后胆红素、碱性磷酸酶等酶学指标均有不同程度下降,临床症状明显改善,无严重并发症发生。结论内镜对于肝移植术后胆道并发症的诊断与治疗安全而有效,避免了患者再次外科手术。

ERCP对肝移植术后胆漏的诊疗效果评价

目的：评估经内镜逆行胰胆管造影术（ERCP）在原位肝移植术（OLT）后对胆漏的诊疗作用。方法回顾分析我院2013年3月—2016年2月间共12例OLT术后经临床、磁共振胰胆管成像术（MRCP）或术中ERCP证实为胆漏患者的资料，包括胆漏及其合并症的临床症状、发生时间、发生部位、诊疗过程、疗效等临床资料，评价ERCP的诊疗价值。结果本组12例均为男性，年龄35~62岁，平均（49.75±8.55）岁。11例成功行经内镜鼻胆管引流术（ENBD），成功率91.7%；胆漏治愈率91.7%（11/12）；无ERCP相关严重并发症及死亡病例发生；其中9例合并胆管狭窄和（或）伴胆管结石/胆栓者在进行初次ERCP诊疗时行内镜下十二指肠乳头括约肌切开术（EST），并于胆漏愈合2周后行进一步ERCP治疗。除1例ENBD未成功者外，其余随访效果良好。结论 ERCP是OLT术后不同类型胆漏的安全及有效的微创治疗方法。

内镜下胆道内支架防治创伤性肝破裂术后胆漏

目的 探讨内镜下胆道内支架在防治创伤性肝破裂术后胆漏中的价值。方法 回顾性分析2000年1月-2014年9月该院收治的42例创伤性肝破裂术后胆漏患者的临床资料,分为手术组和支架组,手术组10例常规行手术治疗,支架组32例行胆道内支架引流治疗,评估胆道内支架在创伤性肝破裂术后胆漏防治中的应用价值。结果 研究中发现3种胆漏类型：肝实质胆漏31例,胆总管胆漏9例,T管窦道漏2例。支架组Sandha胆道造影分型：Low grade型11例,High grade型21例。支架组再手术率、并发症率明显少于手术组,差异有统计学意义（χ2=4.09,P〈0.05;χ2=4.44,〈0.05）;支架组住院时间明显短于手术组,差异有统计学意义（=3.71,〈0.05）。两组在治疗前后的炎症指标有差异。胆道内支架移除时间5~15个月,平均（7.2±2.2）个月。结论内镜逆行性胰胆管造影术（ERCP）能精确诊断胆漏,ERCP胆道内支架可作为严重创伤性肝破裂术后胆漏（评分高、胆漏量大或合并狭窄）的首选治疗方法。

腹腔镜胆囊切除术后胆漏的临床分析

目的:探讨腹腔镜胆囊切除术后胆漏的原因、预防和治疗。方法:回顾分析2000年1月—2011年9月复旦大学附属中山医院青浦分院10例腹腔镜胆囊切除术后胆漏患者的临床资料。结果:1例开腹置管腹腔引流;5例置鼻胆管引流,并继续原腹腔引流,其中1例因腹腔引流管滑脱而剖腹冲洗后重置腹腔引流管;3例置鼻胆管引流,同时行超声引导下穿刺引流;1例开腹行胆管空肠Roux-en-Y吻合;全部患者于2～5周内痊愈。结论:腹腔镜胆囊切除术后出现胆漏应早期充分引流,一旦怀疑胆漏应尽早行经内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)检查,但关键在于预防胆漏。

腹腔镜胆囊切除术中胆管损伤的预防

本组腹腔镜胆囊切除术３００例，术中胆总管损伤２例（０．６７％）．及时中转开腹手术一期修复；术后肝床胆漏肝下包裹性积液１例（０．３３％），经穿刺置管引流治愈。本组无手术死亡及２次手术。本文讨论了腹腔镜胆囊切除术中预防胆道损伤的几项措施，如手术适应证的掌握，术中牵引、分离胆囊的方法及困难病例的处理等。

经内镜鼻胆管引流术治疗腹腔镜胆囊切除术后胆漏

目的总结经内镜鼻胆管引流术(endoscopicn asobiliary drainage,ENBD)治疗腹腔镜胆囊切除术(laparoscop iccholecystectomy,LC)后胆漏的疗效。方法对8例经ENBD治疗的LC术后胆漏患者进行回顾性分析,进行经验总结。结果8例LC术后胆漏患者经ENBD后全部痊愈出院,胆漏愈合时间为6～12d,平均8.5d。结论ENBD是治疗术后胆漏的安全有效的非手术疗法。

肝切除术后胆漏17例临床分析

目的探讨肝切除术后胆漏的原因,提出预防和治疗的方法。方法回顾性分析2007年7月～2011年5月,我科17例肝切除术后胆漏的临床资料。结果 17例胆漏发现时间为术后4～16d,每日引流量10～300ml,引流7～360d后自愈,无1例再次手术。结论肝切除术后可能发生胆漏,术中肝断面的仔细检查,胆管1注水试验以及对高危患者行胆总管T管引流有助于减少胆漏发生。