A Case Report and Literature Review: A Case of Delayed Bile Leakage Following Laparoscopic Cholecystectomy

Background: Delayed bile leakage after laparoscopic cholecystectomy, defined as occurring more than 72 hours after surgery, is a rare and serious complication of laparoscopic cholecystectomy, with an incidence rate of 0.060%. Case Declaration: This case report details a patient diagnosed with delayed bile leakage 43 days after laparoscopic cholecystectomy. The patient was discharged from our hospital after undergoing CT-guided puncture treatment, with no obvious complications identified. The patient was monitored for one year following the procedure, during which time no significant discomfort was reported. Objective: This case report is to analyse and review the clinical manifestations, diagnosis, treatment and prevention of delayed bile leakage after cholecystectomy, with reference to the relevant literature. Results: Delayed bile leakage after laparoscopic cholecystectomy can be prevented, although not eliminated. It is recommended that the operator treat the operation with caution, avoid taking risks, and adhere to careful procedures and strict separation according to the requirements. This approach is key to preventing late bile leakage in the postoperative period.

Risk factors for postoperative bile leakage:a retrospective single-center analysis of 411 hepatectomies

BACKGROUND： The primary focus of the study was to ana- lyze the risk factors for bile leakage after hepatectomy for be- nign or malignant tumors. METHODS： A total of 411 patients who had undergone hepa- tectomy between December 2006 and December 2011 were ret- rospectively analyzed. The severity of bile leakage was graded according to the ISGLS classification. Twenty-eight pre- and postoperative parameters were analyzed. RESULTS： The overall bile leakage incidence was 10.2% （42/411）. The severity of the leakage was classified according to the IS- GLS classification. Bile leakage was detected early in case of abdominal drainage （11.4% vs 1.9%, P=0.034）. It prolonged the time of hospitalization （16 vs 9 days, P=0.001）. In all patients, wedge resection was associated with a higher incidence of bile leakage in contrast to anatomical resections （25.6% vs 4.1%, P〈0.0001） regardless of the underlying liver disease. Furthermore, total vascular exclusion increased risk of bile leakage （P=0.008）. CONCLUSIONS： Bile leakage as a major issue after hepatic resection is related to the postoperative morbidity and the hospitalization time. It is associated with non-anatomical re- section and a total vascular exclusion.

Postoperative bile leakage managed successfully by intrahepatic biliary ablation with ethanol

We report a case of postoperative refractory bile leakage managed successfully by intrahepatic biliary ablation with ethanol. A 75-year-old man diagnosed with hepatocellular carcinoma underwent extended posterior segmentectomy including the caudate lobe and a part of the anterior segment. The hepatic tumor attached to the anterior branch of the bile duct was detached carefully and resected. Fluid drained from the liver surface postoperatively contained high concentrations of total bilirubin, at a constant volume of 150 mL per day. On d 32 after surgery, a fistulogram of the drainage tube demonstrated an enhancement of the anterior bile duct. Endoscopic retrograde cholangiography demonstrated complete obstruction of the proximal anterior bile duct and no enhancement of the peripheral anterior bile duct. On d 46 after surgery, a retrograde transhepatic biliary drainage （RTBD） tube was inserted into the anterior bile duct under open surgery. However, a contrast study of RTBD taken 7 mo post-surgery revealed that the fistula remained patent despite prolonged conservative man- agement, so we decided to perform ethanol ablation of the isolated bile duct. Four mL pure ethanol was injected into the isolated anterior bile duct for ten minutes, the procedure being repeated five times a week. Following 23 attempts, the volume of bile juice reached less than 10 mL per day. The RTBD was clamped and removed two days later. After RTBD removal, the patient had no complaints or symptoms. Follow-up magnetic resonance imaging demonstrated atrophy of the ethanol-injected anterior segment without liver abscess formation.

Risk factors for bile leakage after hepatectomy

In the current issue, Panaro et al presented a retro- spective single-center study on 411 hepatectomies for benign and malignant liver tumors. After exclusion of hilar cholangiocarcinomas and hepatectomies with simultaneous biliary or pancreatic resection, risk factors for postoperative bile leakage were analyzed. Progress in preoperative assessment （e.g. modern imaging studies, liver function tests）, liver preconditioning （e.g. portal vein embolization）, improving perioperative care, and advances in surgical techniques （e.g. two stage hepatec- tomies, liver partition with portal vein ligation for staged hepatectomy） enable curative resections even for advanced hepatic malignancies with reasonable mortality rates and constantly improving oncological outcomes.

Iatrogenic bile duct injuries from biliary tract surgery

BACKGROUND:Cholecystectomy is the most commonly performed procedure in general surgery.However,bile duct injury is a rare but still one of the most common complications.These injuries sometimes present variably after primary surgery.Timely detection and appropriate management decrease the morbidity and mortality of the operation. METHODS:Five cases of iatrogenic bile duct injury(IBDI) were managed at the Department of Surgery,First Affiliated Hospital,Xi’an Jiaotong University.All the cases who underwent both open and laparoscopic cholecystectomy had persistent injury to the biliary tract and were treated accordingly. RESULTS:Recovery of the patients was uneventful.All patients were followed-up at the surgical outpatient department for six months to three years.So far the patients have shown good recovery. CONCLUSIONS:In cases of IBDI it is necessary to perform the operation under the supervision of an experienced surgeon who is specialized in the repair of bile duct injuries,and it is also necessary to detect and treat the injury as soon as possible to obtain a satisfactory outcome.

Diagnosis and management of cystic duct leakage after laparoscopic cholecystectomy: report of 3 cases

BACKGROUND; Operative complications after laparo- scopic cholecystectomy (LC) vary. Abdominal pain and other symptoms caused by fluid accumulation in the opera- tive area are not uncommon. Cystic duct (CD) leakage is one of the main sources of the fluid. This study was to eva- luate the procedures used in the diagnosis and management of CD leakage after LC. METHOD: The clinical materials of 3 patients with CD leakage after LC were studied retrospectively. RESULTS: Three female patients underwent LC for chronic cholecystitis associated with stones. Their clinical symp- toms were worsened of pre-existed cardiac arrhythmia, bile draining out from drainage tube, and biliary spillage from umbilical incision, respectively. Final diagnosis was made at the 1st, 2nd and 20th post-operative day. Two of the 3 patients were treated laparoscopically. Their opened CD stumps were closed with an endo-loop, with the abdomen irrigated and drained. The other patient was drained with the percutaneous technique, and a biliary stent was inserted under endoscopy. All patients recovered well. CONCLUSIONS: The clinical manifestations of CD leakage are different. Ascites can be found by B-ultrasound. Final diagnosis is dependent on magnetic resonance cholangiog- raphy and/or endoscopic retrograde cholangiopancreatog- raphy. Minimally invasive techniques can be applied to this complication safely and effectively. Reoperarion for closure of the opened CD stump can be fulfilled under laparosco- py. Endoscopic drainage must be accompanied with effec- tive abdominal drainage.

Managing injuries of hepatic duct confluence variants after major hepatobiliary surgery:An algorithmic approach

AIM:To investigate injuries of anatomy variants of hepatic duct confluence during hepatobiliary surgery and their impact on morbidity and mortality of these procedures. An algorithmic approach for the management of these injuries is proposed. METHODS:During a 6-year period 234 patients who had undergone major hepatobiliary surgery were retrospectively reviewed in order to study postoperative bile leakage. Diagnostic workup included endoscopic and magnetic retrograde cholangiopancreatography (E/MRCP), scintigraphy and fistulography. RESULTS:Thirty (12.8%) patients who developed postoperative bile leaks were identified. Endoscopic stenting and percutaneous drainage were successful in 23 patients with bile leaks from the liver cut surface. In the rest seven patients with injuries of hepatic duct confluence, biliary variations were recognized and a stepwise therapeutic approach was considered. Conservative management was successful only in 2 patients. Volume of the liver remnant and functional liver reserve as well as local sepsis were used as criteria for either resection of the corresponding liver segment or construction of a biliary-enteric anastomosis. Two deaths occurred in this group of patients with hepatic duct confluence variants (mortality rate 28.5%). CONCLUSION:Management of major biliary fistulaethat are disconnected from the mainstream of the biliary tree and related to injury of variants of the hepatic duct confluence is extremely challenging. These patients have a grave prognosis and an early surgical procedure has to be considered.

Phlegmonous gastritis after biloma drainage:A case report and review of the literature

BACKGROUND Phlegmonous gastritis(PG)is a rare bacterial infection of the gastric submucosa and is related to septicemia,direct gastric mucosal injury,or the direct influence of infection or inflammation in neighboring organs.Here,we present a patient who had spontaneous biloma caused by choledocholithiasis and then PG resulting from bile leakage after biloma drainage.CASE SUMMARY A 79-year-old man with a medical history of hypertension had persistent diffuse abdominal pain for 4 d.Physical examination showed stable vital signs,icteric sclera,diffuse abdominal tenderness,and muscle guarding.Laboratory tests showed hyperbilirubinemia and bandemia.Contrast computed tomography(CT)of the abdomen showed a dilated common bile duct and left subphrenic abscess.Left subphrenic abscess drainage revealed bilious fluid,and infected biloma was confirmed.Repeated abdominal CT for persistent epigastralgia after drainage showed gastric wall thickening.Esophagogastroduodenoscopy(EGD)showed an edematous,hyperemic gastric mucosa with poor distensibility.The gastric mucosal culture yielded Enterococcus faecalis.PG was diagnosed based on imaging,EGD findings,and gastric mucosal culture.The patient recovered successfully with antibiotic treatment.CONCLUSION PG should be considered in patients with intraabdominal infection,especially from infected organs adjacent to the stomach.

The incidence and severity of post-hepatectomy bile leaks is affected by surgical indications,preoperative chemotherapy,and surgical procedures

Background:Bile leaks are one of the most common complications after liver resection.The International Study Group of Liver Surgery(ISGLS)established a uniform bile leak definition including a severity grading.However,a risk factor assessment according to ISGLS grading as well as the clinical implications has not been studied sufficiently so far.Methods:The incidence and grading of bile leaks according to ISGLS were prospectively documented in 501 consecutive liver resections between July 2012 and December 2016.A multivariate regression analysis was performed for risk factor assessment.Association with other surgical complications,90-day mortality as well as length of hospital stay(LOS)was studied.Results:The total rate of bile leaks in this cohort was 14.0%:2.8%grade A,8.0%grade B,and 3.2%grade C bile leaks were observed.Preoperative chemotherapy or biliary intervention,diagnosis of hilar cholangiocarcinoma,colorectal metastasis,central minor liver resection,major hepatectomy,extended hepatectomy or two-stage hepatectomy,were some of the risk factors leading to bile leaks.The multivariate regression analysis revealed that preoperative chemotherapy,major hepatectomy and biliodigestive reconstruction remained significant independent risk factors for bile leaks.Grade C bile leaks were associated not only with surgical site infection,but also with an increased 90-day mortality and prolonged LOS.Conclusions:The preoperative treatment as well as the surgical procedure had significant influence on the incidence and the severity of bile leaks.Grade C bile leaks were clinically most relevant,and led to significant increased LOS,rate of infection,and mortality.