Clinical Factors and Postoperative Impact of Bile Leak After Liver Resection

The impact of bile leakage on long-term prognosis in primary liver cancers after hepatectomy: A propensity-score-matched study

BACKGROUND

The impact of bile leakage (BL) on the long-term prognosis in patients with primary liver cancers after hepatectomy remains unclear.

METHODS

One thousand nine hundred and seventy-one consecutive patients with primary liver cancers who underwent curative hepatectomy were enrolled. 75 patients encountered BL, including 34 long-time BL (LTBL) and 41 short-time BL (STBL) according to 4-weeks demarcation. Variables associated with BL were identified using multiple logistic regression analysis. 75 patients without BL were enrolled into the Non-BL group using a one-to-one propensity score matched analysis before assessing the impact of BL on the long-term prognosis. The levels of interleukin-6 (IL-6) and C-reactive protein (CRP) in the serum and drain fluid were detected and compared.

RESULTS

The tumor size, type of liver cancer, operation time, blood loss and blood transfusion were independent risk factors for BL. The long-term survival showed no difference between the patients with and without BL (p > 0.05), while the LTBL was a significant predictor of poor long-term prognosis (p < 0.001). Compared with the patients without BL, the patients with BL had a higher level of IL-6 from postoperative day (POD) 1 to POD 60, and a higher level of CRP from POD 7 to POD 60. By POD 60, the levels of IL-6 and CRP hadn't restored to the normal level in the LTBL group.

CONCLUSIONS

The LTBL has a negative impact on the long-term prognosis of patients with primary liver cancers after hepatectomy, in which the inflammatory responses may play a pivotal role.

Efficacy of the bile leak test using contrast-enhanced intraoperative ultrasonic cholangiography in liver resection: a study protocol for a non-randomised, prospective, off-label, single-arm trial

INTRODUCTION

Bile leak is still a major complication after liver resection to be improved. To intraoperatively detect this adverse complication, leak test is commonly performed after hepatic resection. However, by the conventional leak test, it is often difficult to know whether the test reagent reaches to intrahepatic bile duct near cut surface of liver with adequate volume and pressure to identify the existence of bile leak. Thus, in order to perform leak test more accurately, this study aims to evaluate the efficacy and safety of the leak test using contrast-enhanced intraoperative ultrasonic cholangiography (CE-IOUSC), which was reported by our group as a procedure for detection of bile duct.

METHODS AND ANALYSIS

The current study is a non-randomised, prospective, off-label, single-arm clinical trial for patients who undergo liver resection. A total of 100 patients will be enrolled. After completion of liver resection, the leak test is performed with CE-IOUSC using Sonazoid as a contrast agent to visualise dye injection into the intrahepatic bile duct. The primary endpoint is the success of the leak test, defined as clear visualisation of intrahepatic bile duct around cut surface by ultrasonography that indicates enough volume of dye injection. Secondary endpoints are postoperative bile leak and all adverse events related to CE-IOUSC. The findings obtained through this study will establish this procedure to assist surgeons for adequately performing the leak test, precisely detecting intraoperative biliary leak strictly and reducing postoperative bile leak.

ETHICS AND DISSEMINATION

The protocol is approved by Institutional Review Boards of Kobe University Hospital (No.290069). Our findings will be widely disseminated through conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

UMIN000031236 and jRCTs051180027.

Scoring criteria for determining the safety of liver resection for malignant liver tumors

BACKGROUND

Liver resection has become safer as it has become less invasive. However, the minimum residual liver volume (RLV) required to maintain homeostasis is unclear. Furthermore, the formulae used to calculate standard liver volume (SLV) are complex.

AIM

To review previously reported SLV formulae and the methods used to evaluate the minimum RLV, and explore the association between liver volume and mortality.

METHODS

A systematic review of Medline, PubMed, and grey literature was performed. References in the retrieved articles were cross-checked manually to obtain further studies. The last search was conducted on January 20, 2019. We developed an SLV formula using data for 86 consecutive patients who underwent hepatectomy at our institution between July 2009 and August 2011.

RESULTS

Linear regression analysis revealed the following formula: SLV (mL) = 822.7 × body surface area (BSA) − 183.2 (R² = 0.419 and R = 0.644, P < 0.001). We retrieved 25 studies relating to SLV formulae and 12 studies about the RLV required for safe liver resection. Although the previously reported formulae included various coefficient and constant values, a simplified version of the SLV, the common SLV (cSLV), can be calculated as follows: cSLV (mL) = 710 or 770 × BSA. The minimum RLV for normal and damaged livers ranged from 20%-40% and 30%-50%, respectively. The Sapporo score indicated that the minimum RLV ranges from 35%-95% depending on liver function.

CONCLUSION

We reviewed SLV formulae and the minimum RLV required for safe liver resection. The Sapporo score is the only liver function-based method for determining the minimum RLV.

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.

Is bile leakage after hepatic resection associated with impaired long-term survival?

BACKGROUND

Bile leakage (BL) is a frequent and severe complication following liver surgery. The aim of this study was to evaluate risk factors for BL, related other complications and association with long-term survival.

METHODS

This study included all patients undergoing hepatectomy in a single centre from 2005 to 2016. Perioperative risk factors related to BL were identified using univariable and multivariable analysis. Kaplan-Meier method was used for survival analysis.

RESULTS

BL occurred in 48 of 458 patients (11%). BLs were more frequent in patients after major hepatectomy (p = 0.001). Portal vein embolization, bilioenteric-anastomosis, lymphadenectomy, vascular reconstruction and operative time were significant factors for developing BL. Comparing patients with or without BL, BL was more commonly associated with other postoperative complications (p = 0.001), especially acute kidney failure and surgical-site-infections. There was no difference in 90-day-mortality (p = 0.124). The median disease-free survival was comparable (17 vs. 15 months, p = 0.976), also no difference was observed when stratifying for different tumour entities. There was no difference in median overall survival (OS) among malignant disease (35 vs. 47 months, p = 0.200) and in 3-year OS (46% vs. 59%). Multivariate analysis confirmed that postoperative liver failure and major hepatectomy were risk factors for reduced OS (p = 0.010).

CONCLUSIONS

Many concerns have been raised regarding tumour progression after major complications. In this study, we only found a relevant influence of BL on OS in pCC, whereas no association was seen in other cancer types, indicating that tumour progression might be triggered by BL in cancer types arising from the bile ducts itself.