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Journal ArticleDOI

Posthepatectomy bile leakage: how to manage.

01 Jan 2012-Digestive Surgery (Karger Publishers)-Vol. 29, Iss: 1, pp 48-53
TL;DR: The incidence of posthepatectomy biliary leakage has decreased over time, while PTD and endoscopic stenting are effective treatment modalities.
Abstract: Background: Biliary leakage after liver resection continues to be reported. Management of bile leakage has changed in recent years, with nowadays non-surgical procedures as the preferred treatment. Methods: Biliary leakage and management were assessed in 381 patients who underwent liver resection between January 2005 and April 2011. Results: The overall rate of biliary leakage after liver resection was 5.0%, with a higher incidence in patients who had undergone concomitant hepaticojejunostomy (HJ; 13.6 vs. 3.2%). Hospital stay (p = 0.047), major resections (p = 0.018), operation time (p = 0.011), and relaparotomy (p = 0.002) were risk factors for postoperative bile leakage. Multivariate analysis identified relaparotomy as an independent factor (OR 4.216, p = 0.034). Bile leakage in patients without HJ (n = 10) was managed in 6 patients by percutaneous transhepatic biliary drainage (PTD), and in 3 patients by endoscopic drainage. One patient was treated surgically. All patients with an HJ and postoperative bile leakage (n = 9) underwent PTD. Conclusion: The incidence of posthepatectomy biliary leakage has decreased over time, while PTD and endoscopic stenting are effective treatment modalities. PTD is the treatment of choice in bile leakage after resection combined with HJ.

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Journal ArticleDOI
TL;DR: Hepatic portal reocclusion effectively reduced the incidence of bile leakage compared to the traditional procedure, without significantly affecting liver function, therefore, this method might be an alternative to other tests for biles leakage.
Abstract: Background/Aims: To explore the possibility and feasibility of hepatic portal reocclusion for detecting bile leakage during hepatectomy. Methods: Data were prospectively collected from 200 patients who underwent hepatectomy alone for removal of various benign or malignant tumors between March 2014 and November 2014. The surgical procedure used a conventional method for all patients, and one additional step (hepatic portal reocclusion) was included in group B. The postoperative outcomes of the patients in group A (subjected to the traditional procedure) and group B (subjected to hepatic portal reocclusion) were compared during the same period, and the incidence rates of postoperative bile leakage and other complications in the 2 groups were also analyzed. Results: The incidence of postoperative bile leakage in group B was significantly lower than that in group A (1.0 vs. 9.2%, p = 0.009), although no significant differences in postoperative indicators of liver dysfunction and other complications were observed between the 2 groups (p > 0.05). Conclusions: Hepatic portal reocclusion effectively reduced the incidence of bile leakage compared to the traditional procedure, without significantly affecting liver function. Therefore, this method might be an alternative to other tests for bile leakage.

3 citations

Journal ArticleDOI
19 Mar 2021-Hpb
TL;DR: In this paper, the authors evaluated the effectiveness and safety of percutaneous transhepatic approach (PTA) to drain bile leak after hepato-pancreato-biliary (HPB) surgery.
Abstract: Background Bile leak (BL) after hepato-pancreato-biliary (HPB) surgery is associated with significant morbidity and mortality. Aim of this study was to evaluate effectiveness and safety of percutaneous transhepatic approach (PTA) to drainage BL after HPB surgery. Methods Between 2006 and 2018, consecutive patients who were referred to interventional radiology units of three tertiary referral hospitals were retrospectively identified. Technical success and clinical success were analyzed and evaluated according to surgery type, BL-site and grade, catheter size and biochemical variables. Complications of PTA were reported. Results One-hundred-eighty-five patients underwent PTA for BL. Technical success was 100%. Clinical success was 78% with a median (range) resolution time of 21 (5–221) days. Increased clinical success was associated with patients who underwent hepaticresection (86%,p = 0,168) or cholecystectomy (86%,p = 0,112) while low success rate was associated to liver-transplantation (56%,p Conclusion This study based on a large cohort of patients demonstrated that PTA is a valid and safe approach in BL treatment after HPB surgery.

3 citations

Journal ArticleDOI
TL;DR: HJ leak is the second common anastomotic failure after pancreaticoduodenectomy (PD), but only a few studies have focused on this complication and it may be associated with nutritional status, width of common bile duct and surgical procedures.
Abstract: Background: Hepaticojejunostomy (HJ) leak is the second common anastomotic failure after pancreaticoduodenectomy (PD), but only a few studies have focused on this complication. We evaluated the incidence of HJ leak after PD and described its presentation, treatment, and outcome. Methods: Records of 292 consecutive patients who underwent PD between 2007 and 2014 were retrospectively analysed. Clinicopathologic data were compared with patients without HJ leaks, and presentation, radiologic findings, treatment, and outcome of HJ leaks were analysed. Results: HJ leak was identified in 14 (4.8%) patients. Low serum albumin on postoperative day 1 (POD1) was associated with an increased risk, while dilation of common hepatic duct and preoperative biliary decompression were two protected factors. Median postoperative day of diagnosis was 5 (range, 1-15). Typical clinical signs included bilious drainage in the surgically placed drains, with fever, abdominal pain and leukocytosis. Patients with HJ leaks had more pancreatic fistulas and other complications included Intra-abdominal abscess, wound infection and delayed gastric emptying. 4 (29%) patients were treated operatively, 5 required percutaneous drainage and 5 underwent conservative management. One patient died in hospital, resulting in a mortality of 7%. Conclusion: Hepaticojejunostomy leaks are rare after PD. The complication severity ranges from trivial to life threatening. It may be associated with nutritional status, width of common bile duct and surgical procedures. Surgical interventions are required for more than half of HJ leaks. A good outcome can be expected.

3 citations


Additional excerpts

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Journal ArticleDOI
01 Aug 2015-Chirurg
TL;DR: The International Study Group of Liver Surgery (ISGLS) as mentioned in this paper defined leberversagen as Drainagebilirubin-Serumbilirubain-Ratio > 3 an Tag 3 or spater oder interventionelle/operative revision aufgrund biliarer peritonitis definiert.
Abstract: Die International Study Group of Liver Surgery (ISGLS) hat Leberversagen nach Leberresektion durch pathologische Werte fur INR und Bilirubin an Tag 5 nach Resektion definiert. Das Auftreten einer Galleleckage wurde als Drainagebilirubin-Serumbilirubin-Ratio > 3 an Tag 3 oder spater oder interventionelle/operative Revision aufgrund biliarer Peritonitis definiert. Es erfolgt eine konfirmatorische explorative Analyse. Alle primaren Leberresektionen in den Jahren 2009 und 2010 wurden ausgewertet. Hauptzielgrosen waren postoperatives Leberversagen und Galleleckage nach ISGLS-Definition. Nebenzielgrosen waren postoperative Komplikationen und 90-Tages-Letalitat. Ergebnisse werden in Medianwerten (Min.; Max.) dargestellt. Es konnten 214 primare Leberresektionen ausgewertet werden. Die Patienten waren 61,5 Jahre (18; 83) alt. Die Inzidenz des Leberversagens lag bei 7,4 % (16 von 214); 7 verstarben. Bei 31 % (65 von 214) zeigte sich eine Galleleckage. 14 (23 %) entwickelten eine Typ-B-, ein Patient (5 %) eine Typ-C-Leckage. 50 Leckagen (Grad A) waren konservativ therapierbar. Die Inzidenz der klinisch relevanten Galleleckagen lag bei 7 % (15 von 214). Die Sensitivitat der Definition war 100 %, die Spezifitat 75 %. Komplikationen nach Dindo-Clavien > 3b traten bei 10,2 % auf, eine Sepsis bei 5,6 %. Die 90-Tages-Letalitat betrug 6,5 %. Multivariate Analysen lieferten keine unabhangig pradiktiven Faktoren fur das Auftreten von Galleleckage oder Leberversagens. Die Definition der ISGLS fur Leberversagen im postoperativen Verlauf ist in unserem Kollektiv valide. Die Inzidenz perioperativer Galleleckage wird mit der vorliegenden Definition uberschatzt und fuhrt zu einer grosen Zahl an falsch-positiven klinisch irrelevanten Fallen.

3 citations

References
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Journal ArticleDOI
TL;DR: The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.
Abstract: Growing demand for health care, rising costs, constrained resources, and evidence of variations in clinical practice have triggered interest in measuring and improving the quality of health care delivery. For a valuable quality assessment, relevant data on outcome must be obtained in a standardized and reproducible manner to allow comparison among different centers, between different therapies and within a center over time.1–3 Objective and reliable outcome data are increasingly requested by patients and payers (government or private insurance) to assess quality and costs of health care. Moreover, health policy makers point out that the availability of comparative data on individual hospital's and physician's performance represents a powerful market force, which may contribute to limit the costs of health care while improving quality.4 Conclusive assessments of surgical procedures remain limited by the lack of consensus on how to define complications and to stratify them by severity.1,5–8 In 1992, we proposed general principles to classify complications of surgery based on a therapy-oriented, 4-level severity grading.1 Subsequently, the severity grading was refined and applied to compare the results of laparoscopic versus open cholecystectomy9 and liver transplantation.10 This classification has also been used by others11–13 and was recently suggested to serve as the basis to assess the outcome of living related liver transplantation in the United States (J. Trotter, personal communication). However, the classification system has not yet been widely used in the surgical literature. The strength of the previous classification relied on the principle of grading complications based on the therapy used to treat the complication. This approach allows identification of most complications and prevents down-rating of major negative outcomes. This is particularly important in retrospective analyses. However, we felt that modifications were necessary, particularly in grading life-threatening complications and long-term disability due to a complication. We also felt that the duration of the hospital stay can no longer be used as a criterion to grade complications. Although definitions of negative outcomes rely to a large extend on subjective “value” appraisals, the grading system must be tested in a large cohort of patients. Finally, a classification is useful only if widely accepted and applied throughout different countries and surgical cultures. Such a validation was not done with the previous classification. Therefore, the aim of the current study was 3-fold: first, to propose an improved classification of surgical complications based on our experience gained with the previous classification1; second, to test this classification in a large cohort of patients who underwent general surgery; and third, to assess the reproducibility and acceptability of the classification through an international survey.

23,435 citations

Journal ArticleDOI
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

Journal ArticleDOI
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.

202 citations

Journal ArticleDOI
TL;DR: The aim of this study was to identify the perioperative risk factors for postoperative bile leakage after hepatic resection and to propose a treatment strategy for such leakage when it does occur, and to show that patients with involvement of the proximal bile duct were slower to heal than those with no demonstrable biles duct involvement.
Abstract: The aim of this study was to identify the perioperative risk factors for postoperative bile leakage after hepatic resection and to propose a treatment strategy for such leakage when it does occur. Between 1992 and 2000 a total of 313 hepatic resections without choledocojejunal anastomosis were performed at our institute. Risk factors related to bile leakage were identified with univariate analysis, and strategies were evaluated in relation to the findings of postoperative fistulography. Postoperative bile leakage developed in 17 patients (5.4%). Univariate analysis identified high risk factors as advanced age, a wide surface area of the incision (bile leakage group versus no bile leakage group: 102.1 vs. 66.4 cm2, p < 0.05), and exposure of Glisson’s sheath at the cut surface (e.g., central bisegmentectomy, S4, S8 subsegmentectomy). Groupings of patients by their postoperative fistulography results showed that patients with involvement of the proximal bile duct were slower to heal than those with no demonstrable bile duct involvement. The one patient whose fistulogram demonstrated peripheral bile duct involvement had uncontrollable leakage and required reoperation. Hepatectomies with a wide surface area and those that expose the major Glisson’s sheath present serious risk factors for bile leakage. When the fistulogram shows proximal bile duct involvement, endoscopic nasobiliary tube drainage is necessary; when the fistulogram shows peripheral bile duct involvement, reoperation is needed.

168 citations

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