Bile Leakage and Liver Resection: Where Is the Risk?
TL;DR: Hematectomies including segment 4, especially if performed for peripheral cholangiocarcinoma, lead to a high risk for postoperative bile leakage, and intraoperative use of fibrin glue may reduce the risk of postoperativebile leakage.
Abstract: Hypothesis The knowledge of risk factors for bile leakage after liver resection could reduce its incidence. Design Retrospective study. Setting Tertiary care referral center. Patients The study included 610 patients who underwent liver resection from January 1, 1989, through January 31, 2003. Interventions Liver resections without biliary anastomoses. Main Outcome Measures Bile leakage incidence and its correlation to preoperative and intraoperative patient characteristics. Results Postoperative bile leakage occurred in 22 (3.6%) of 610 patients. Univariate analysis showed that cirrhosis ( P = .05) or intraoperative use of fibrin glue ( P = .01) was associated with a lower incidence of bile leakage. Moreover, the following factors were significant predictors of bile leakage: peripheral cholangiocarcinoma ( P P = .03), left hepatectomy extended to segment 1 ( P P = .006), and hepatectomy including segment 1 ( P = .001) or segment 4 ( P = .003). At multivariate analysis, use of fibrin glue was an independent protective factor (relative risk = 0.38, P = .046), whereas peripheral cholangiocarcinoma (relative risk = 5.47, P = .02) and resection of segment 4 (relative risk = 3.10, P = .02) were independent risk factors for bile leakage. Conclusions Hepatectomies including segment 4, especially if performed for peripheral cholangiocarcinoma, lead to a high risk for postoperative bile leakage. Intraoperative use of fibrin glue may reduce the risk of postoperative bile leakage.
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Heidelberg University1, University of Edinburgh2, Flinders Medical Centre3, University of Hong Kong4, Nagoya University5, Royal Prince Alfred Hospital6, University of Tokyo7, University of Melbourne8, St. Vincent's Health System9, Alfred Hospital10, University of Adelaide11, Royal North Shore Hospital12, University of Texas MD Anderson Cancer Center13, Toronto General Hospital14, University of Girona15, Memorial Sloan Kettering Cancer Center16
TL;DR: A uniform definition and severity grading of bile leakage is proposed to enable a standardized comparison of the results of different clinical trials and may facilitate an objective evaluation of diagnostic and therapeutic modalities in the field of hepatobiliary and pancreatic operative therapy.
1,240 citations
TL;DR: Two-step hepatic resection performing surgical exploration, PVL, and ISS results in a marked and rapid hypertrophy of functional liver tissue and enables curative resection of marginally resectable liver tumors or metastases in patients that might otherwise be regarded as palliative.
Abstract: Objective:To evaluate a new 2-step technique for obtaining adequate but short-term parenchymal hypertrophy in oncologic patients requiring extended right hepatic resection with limited functional reserve.Background:Patients presenting with primary or metastatic liver tumors often face the dilemma th
1,004 citations
TL;DR: Simultaneous colorectal and minor hepatic resections are safe and should be performed for most patients with SCRLM and caution should be exercised before performing simultaneous coloreCTal and major liver metastases resections.
Abstract: Background
The safety of simultaneous resections of colorectal cancer and synchronous liver metastases (SCRLM) is not established. This multi-institutional retrospective study compared postoperative outcomes after simultaneous and staged colorectal and hepatic resections.
387 citations
TL;DR: Multidetector CT and MR imaging, with the added value of image postprocessing, allow accurate identification of areas at risk for venous congestion or devascularization, and may influence surgical planning with regard to the extent of hepatic resection or the need for vascular reconstruction.
Abstract: Accurate preoperative assessment of the hepatic vascular and biliary anatomy is essential to ensure safe and successful hepatic surgery. Such surgical procedures range from the more complex, like tumor resection and partial hepatectomy for living donor liver transplantation, to others performed more routinely, like laparoscopic cholecystectomy. Modern noninvasive diagnostic imaging techniques, such as multidetector computed tomography (CT) and magnetic resonance (MR) imaging performed with liver-specific contrast agents with biliary excretion, have replaced conventional angiography and endoscopic cholangiography for evaluation of the hepatic vascular and biliary anatomy. These techniques help determine the best hepatectomy plane and help identify patients in whom additional surgical steps will be required. Preoperative knowledge of hepatic vascular and biliary anatomic variants is mandatory for surgical planning and to help reduce postoperative complications. Multidetector CT and MR imaging, with the added value of image postprocessing, allow accurate identification of areas at risk for venous congestion or devascularization. This information may influence surgical planning with regard to the extent of hepatic resection or the need for vascular reconstruction.
228 citations
TL;DR: Hepatectomy can be considered safe when FRL is >26.5% in patients with healthy liver and >31% in Patients with impaired liver function, and the FRL did not correlate with postoperative mortality and morbidity.
Abstract: Background The future remnant liver (FRL) limit for safe major hepatectomy with low risk of postoperative liver failure has not yet been well defined. Methods Between April 2000 and September 2004, every patient scheduled for major hepatectomy in our institution underwent CT-volumetry of FRL. Patients with FRL 2 mg/100 ml) (group B). Liver dysfunction was defined as both PT 5 mg/100 ml for three or more consecutive days. Results A total of 119 patients were analyzed, 72 in group A and 47 in group B. The FRL value was the only significant risk factor for postoperative liver dysfunction in the univariate and multivariate analysis (p = 0.009). The FRL did not correlate with postoperative mortality and morbidity. Bilirubin and prothrombin time (PT) on days 3 and 7 were significantly correlated to FRL in both groups. In group A, patients with postoperative liver dysfunction had a FRL 26.5% in patients with healthy liver and >31% in patients with impaired liver function.
219 citations
Cites background from "Bile Leakage and Liver Resection: W..."
...defined as the drainage of 50 ml or more of bile from the surgical drain or from drainage of an abdominal collection, over a period of 3 days or more [12]....
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...Main causes of postoperative morbidity were pulmonary complications and bile leakage; both complications are probably more directly related to the type of dissection [23] and to the transection plane [12, 24] than to the extent of the hepatectomy....
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References
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TL;DR: Assessment of the nature of changes in the field of hepatic resectional surgery and their impact on perioperative outcome to establish a baseline for this type of surgery.
Abstract: Objective
To assess the nature of changes in the field of hepatic resectional surgery and their impact on perioperative outcome.
1,399 citations
TL;DR: Liver resection can be performed without mortality provided that it is carried out in a high-volume medical center by well-trained hepatobiliary surgeons paying meticulous attention to the balance between the liver functional reserve and the volume of liver to be removed.
Abstract: Background Despite improvements in diagnostic and surgical techniques, operative mortality associated with liver resection is still greater than 2% in most of the recent studies. Hypothesis By refining preoperative and postoperative care and surgical skills, liver resection mortality can be decreased to zero. Design Retrospective cohort study to analyze postoperative morbidity and mortality in 1056 consecutive hepatectomies performed at a single medical center during 8 years. Setting Tertiary referral center. Patients A total of 915 patients who underwent 1056 consecutive hepatic resections: 532 for hepatocellular carcinoma, 262 for other primary and secondary liver malignancies, 57 for biliary tract malignancy, 174 for living donor liver transplantation, and 31 for other benign diseases. Main Outcome Measures Operative mortality and morbidity rates. Results No operative mortality occurred. Major complications, as defined by postoperative radiologic or surgical intervention, occurred in 3% of patients with hepatocellular carcinoma, 8% with other liver malignancy, 28% with biliary malignancy, and 5% of living donor liver transplantation donors. Using multiple logistic regression, independent risk factors associated with major complications were operative blood loss of 1000 mL or greater for hepatocellular carcinoma and total bilirubin level of 1.0 mg/dL or greater (≥17 µmol/L) and operative time greater than 6 hours for other liver malignancy. No independent factors associated with major complications were identified for biliary malignancy or for living donor liver transplantation donors among the variables investigated in this study. Conclusions Liver resection can be performed without mortality provided that it is carried out in a high-volume medical center by well-trained hepatobiliary surgeons paying meticulous attention to the balance between the liver functional reserve and the volume of liver to be removed.
779 citations
"Bile Leakage and Liver Resection: W..." refers background in this paper
...6% to 12% in recent large series.(1,3,5) Bile leakage is one of the most...
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TL;DR: The Brisbane 2000 system of nomenclature of hepatic anatomy and resections was introduced to provide a universal terminology in an area that was plagued by confusing and inappropriate terminology.
Abstract: The Brisbane 2000 system of nomenclature of hepatic anatomy and resections was introduced to provide a universal terminology in an area that was plagued by confusing and inappropriate terminology. The article describes historical developments central to the emergence of the new terminology and describes the terminology, its attributes, and rules of application.
735 citations
"Bile Leakage and Liver Resection: W..." refers background in this paper
...Nomenclature of segments and types of operations follow the Brisbane 2000 terminology.(9)...
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TL;DR: Perioperative outcome has improved despite extending the indication of hepatectomy to more high-risk patients, and the role of hepATEctomy in the management of hepatobiliary diseases can be expanded.
Abstract: Objective: To assess the trends in perioperative outcome of hepatectomy for hepatobiliary diseases. Methods: Data of 1222 consecutive patients who underwent hepatectomy for hepatobiliary diseases from July 1989 to June 2003 in a tertiary institution were collected prospectively. Perioperative outcome of patients in the first (group I) and second (group II) halves of this period was compared. Factors associated with morbidity and mortality were analyzed. Results: Diagnoses included hepatocellular carcinoma (n = 734), other liver cancers (n = 257), extrahepatic biliary malignancies (n = 43), hepatolithiasis (n = 101), benign liver tumors (n = 61), and other diseases (n = 26). The majority of patients (61.8%) underwent major hepatectomy of ≥3 segments. The overall hospital mortality and morbidity were 4.9% and 32.4%, respectively. The number of hepatectomies increased from 402 in group I to 820 in group II, partly as a result of more liberal patient selection. Group II had more elderly patients (P = 0.006), more patients with comorbid illnesses (P = 0.001), and significantly worse liver function. Nonetheless. group II had lower blood loss (median 750 versus 1450 mL, P < 0.001), perioperative transfusion (17.3°K, versus 67.7%, P < 0.0111), morbidity (30.0% versus 37.3%, P = 0.012), and hospital mortality (3.7% versus 7.5%, P = 0.004). On multivariate analysis, hypoalbuminemia, thrombocytopenia, elevated serum creatinine, major hepatic resection, and transfusion were the significant predictors of hospital mortality, whereas concomitant extrahepatic procedure, thrombocytopenia, and transfusion were the predictors of morbidity. Conclusions: Perioperative outcome has improved despite extending the indication of hepatectomy to more high-risk patients. The role of hepatectomy in the management of hepatobiliary diseases can be expanded. Reduced perioperative transfusion is the main contributory factor for improved outcome.
659 citations
TL;DR: Patients with bile leakage from the hepatic hilum and postoperative uncontrollable ascites tend to have a poor prognosis, especially when a high-risk surgical procedure is performed in patients with liver cirrhosis, and more careful surgical procedures and use of an intraoperative biles leakage test are recommended.
Abstract: Because of recent advances in liver surgery, hepatic resections are being performed with increasing frequency, and the surgical death rate for such resections is decreasing. 1–7 Bile leakage, of course, is the primary complication occurring after liver surgery, and it can not only debase the quality of the postoperative course of patients, but also can lead to hospital death. Despite a significant decrease in the overall surgical complication rate in hepatic resections, the rate of bile leakage has not changed, with an incidence of 4.8% to 7.6% reported in recent large series. 2–8 The presence of bile, blood, and devitalized tissues in the dead space after hepatectomy may provide the ideal environment for bacterial growth and impair the normal host defense mechanisms. 9, 10 The combination of sudden reduction in the liver volume and development of an intraperitoneal septic complication after hepatectomy (IPSCH) frequently results in liver failure, leading to a grave prognosis. 11
The aims of this study were, therefore, to clarify the perioperative risk factors for postoperative bile leakage after hepatic resection, to evaluate the intraoperative bile leakage test as a preventive measure, and to propose a treatment strategy for postoperative bile leakage according to the outcome of these patients.
312 citations
"Bile Leakage and Liver Resection: W..." refers background in this paper
...We hope that an improved understanding of associated risk factors can lead to further reductions.(5) Unfortunately, few articles on the risk factors for bile leakage after hepatectomy have been published, and few have focused on the technical and anatomical variables that may contribute to the risk of biliary complications....
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...higher postoperative mortality, and longer in-hospital stay.(5) Risk factors for postoperative bile leakage(5,6) and the role of intraoperative tests to prevent it(7,8) are still...
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...6% to 12% in recent large series.(1,3,5) Bile leakage is one of the most...
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