Interrupted versus continuous suture technique for biliary-enteric anastomosis: randomized clinical trial

Imaging and management of complications post biliary-enteric anastomosis

Biliary-enteric anastomosis is a common surgical procedure for benign and malignant pathologies involving bile ducts, pancreas and duodenum, as well as during liver transplantation. Imaging is key in detecting potential complications. Ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and nuclear scintigraphy provide complementary information. Ultrasound offers real-time assessment of bile duct dilation and fluid collection. CT scan, due to its wide availability, is often performed first and provides detailed cross-sectional anatomy. MRI, including MR cholangiography, excels in visualizing bile ducts and detecting subtle changes in anastomosis integrity. Common complications of BEA include bile leak, biliary anastomotic stricture, and cholangitis, each presenting with distinct imaging features. Effective imaging allows for early detection and management of these complications, improving patient outcomes. This review discusses the role of imaging in assessing post-BEA complications and emphasizes the importance of multimodal imaging approaches in the comprehensive evaluation of BEA and its complications.

Continuous or Interrupted Suture for Hepaticojejunostomy in Pancreaticoduodenectomy (The HEKTIK Trial): Findings of a Randomized, Controlled, Single-Center Superiority Trial

BACKGROUND

Over 6000 pancreaticoduodenectomies are per - formed each year in Germany, and hepaticojejunostomy is a crucial step of the procedure. An anastomotic leak of hepaticojejunostomy can cause major postoperative complications. The aim of this trial was to compare the morbidity and efficiency of continuous versus interrupted suturing for hepaticojejunostomy in pancreaticoduo - denectomy.

METHODS

In a randomized, controlled, single-center trial (German Clinical Trials Register No. DRKS00024395), patients scheduled for elective open partial pancreaticoduodenectomy with hepaticoje - junostomy between January 2020 and May 2023 were randomly assigned in a 1:1 ratio to suturing of the hepaticojejunostomy with either a continuous or an interrupted technique. The primary endpoint was anastomotic leakage from the hepaticojejunostomy in the first three days after surgery. Further perioperative parameters were secondary endpoints, including later leakage, other complications, the duration of hepaticojejunostomy, and the cost of hepaticojejunostomy.

RESULTS

The 100 patients in the trial consisted of 50 in each group. The rate of early anastomotic leakage was 2% in both groups (95% confidence interval for the difference, [-5.5%; 5.5%]; p = 1.000). As for the secondary endpoints, there were no relevant intergroup differences in any other short-term or long-term morbidity parameters. Continuous suturing of the hepaticojejunostomy was, however, 31% faster and 68% cheaper in material costs.

CONCLUSION

These data imply that continuous and interrupted suturing techniques yield equally good clinical outcomes in hepaticojejunostomies of hepatic ducts with diameter 5 mm or more. Continuous suturing is, however, both faster and cheaper.

The effectiveness of combined extrahepatic bile duct resection in radically resected cases with intrahepatic cholangiocarcinoma: a SEER-based retrospective cohort study and an external validation

OBJECTIVE

To evaluate the effectiveness of the combined extrahepatic bile duct resection (EHBDR) in cases with intrahepatic cholangiocarcinoma (IHCC) in terms of clinicopathological features and long-term survival.

METHODS

Radically resected cases with IHCC from 2000 to 2020 were identified from Surveillance, Epidemiology, and End Results (SEER) database. Comparative analyses were performed between resected IHCC patients who received EHBDR and those without EHBDR. Moreover, an external validation was further performed based on a single-center cohort.

RESULTS

A total of 1521 radically resected cases with IHCC (EHBDR: 189) were identified from the SEER database. Comparable age, sex, race, marital status, liver cirrhosis, differentiation status, and adjuvant chemotherapy were acquired between the two groups. EHBDR was associated with a higher incidence of adequate lymphadenectomy ( P <0.001). The incidence of cases with T3-4 or N+ disease was significantly higher in EHBDR group ( P <0.001). Adjuvant radiotherapy was more frequently performed in cases with EHBDR ( P <0.001). EHBDR failed to bring any survival benefit and was associated with a worse prognosis even after matching. Similar findings have also been revealed in the external validation cohort ( n =522, EHBDR: 117). EHBDR was associated with more extended resections, more aggressive tumor biological features, and worse prognosis. In the matched validation cohort, EHBDR was still associated with a higher incidence of early recurrence.

CONCLUSION

EHBDR was an indicator of the advanced stage and failed to bring any survival benefit. It is the tumor stage that really determines the prognosis. More in-depth analyses focusing on different situations of EHBDR with more detailed clinical data are required.

Long-term outcomes of choledochoduodenostomy for choledocholithiasis: increased incidence of postoperative cholangitis after total or distal gastrectomy

PURPOSE

Choledochoduodenostomy (CDD) is performed to treat choledocholithiasis (CDL) cases where endoscopic stone removal is difficult. Recognizing CDD characteristics is important for CDL treatment planning.

METHODS

A total of 116 patients, including 33 patients ≥ 80 years old (29 with previous total gastrectomy, 19 with previous distal gastrectomy, 20 with built-up stones, 19 with periampullary diverticulum, 10 with confluence stones, 8 with repetitive recurrent stones, 4 with hard stones, 3 with endoscopic retrograde cholangiography [ERC] not available due to lack of cooperation, 2 with a history of pancreatitis post-ERC, and 2 in whom ERC could not be performed due to a disturbed anatomy) underwent CDD for CDL. Postoperative complications and long-term outcomes were evaluated.

RESULTS

The in-hospital mortality rate was 0%. The morbidity (grade ≥ IIIA according to the Clavien-Dindo classification) rates in the elderly (≥ 80 years old) and non-elderly (51-79 years old) patients were 3.0% (1/33) and 2.4% (2/83), respectively (p = 0.85). Long-term complications included cholangitis in eight (7%) patients, of which three cases were repetitive and seven had an operative history of total or distal gastrectomy. The incidence of postoperative cholangitis after total or distal gastrectomy was 15% (7/48), which was significantly higher than that involving other causes (1.5%, 1/68; p < 0.01). Two patients with cholangitis after total gastrectomy experienced early recurrence of lithiasis at 2 and 9 months after surgery.

CONCLUSIONS

CDD is safe, even in elderly patients. However, a history of total gastrectomy or distal gastrectomy may increase the incidence of postoperative cholangitis.

Continuous versus interrupted anastomotic technique for the hepaticojejunostomy: a prospective cohort study

Background

Interrupted sutures is the gold standard technique of hepaticojejunostomy (HJ) for bilioenteric anastomosis. This study compares the safety and early complications of continuous and interrupted suture HJ.

Methods

A prospective study involving all elective HJ between September 2019 and June 2021 was conducted. Patients with type IV or V biliary strictures, duct diameter less than 8 mm and/or associated vascular injury, and bilateral HJ were excluded. The study patients were divided into two random groups; interrupted and continuous anastomotic technique. Patient demographics, preoperative parameters including pathology (benign vs. malignant), HJ leak, suture time, and postoperative morbidity were recorded.

Results

Total 34 patients were enroled. Eighteen (52.9%) were into interrupted and 16 (47.1%) patients into the continuous group. Both the groups were comparable with regards to demographics, haemoglobin, serum albumin, preoperative cholangitis and biliary stenting. Total three (8.8%) patients in the entire study developed bile leak; interrupted-2 and continuous-1, which was not significant statistically (P=1.0). Similarly, total number of sutures used and the mean operating time to complete anastomosis in the continuous group was significantly lesser than the interrupted group (2.3±0.5 versus 9.6±1.6, P<0.001) and (16.2±3.1 versus 38.6±9.2 min, P<0.001), respectively. There were three (18.8%) re-exploration in the continuous anastomotic technique. Among them, only one re-operation was due to HJ anastomosis failure without mortality, remaining had re-exploration for bleeding (non-HJ).

Conclusions

Both the techniques is safe with comparable morbidity. Further, continuous has an added advantage of decreased anastomotic time and cost.

T‑tube versus internal drainage tube in laparoscopic common bile duct exploration

The 203 patients who underwent laparoscopic common bile duct exploration for choledocholithiasis were retrospectively analyzed. The patients were divided into internal drainage tube group (n=87) and T-tube group (n=116). Total bilirubin, direct bilirubin, alanine aminotransferase (AST), aspartate aminotransferase (ALT), the diameter of common bile duct, number of stones, operation time, intraoperative bleeding, postoperative hospital stay and postoperative complications were compared between the two groups. Possible influencing factors were selected as independent variables, and the operation mode was selected as the dependent variable for multifactor unconditional logistic regression analysis. There were no significant differences in the sex, age, total bilirubin, direct bilirubin, AST, ALT, operation time, intraoperative blood loss, postoperative hospital stay and postoperative biliary leaks between the two groups (P>0.05). The diameter of the common bile duct was smaller and the incidence of multiple stones in the common bile duct was lower in the internal drainage tube group compared with that in the T-tube group (P<0.05). The results of multifactor unconditional logistic regression analysis demonstrated that the diameter of the common bile duct and the number of stones in the common bile duct were associated with the operation mode as influencing factors. In conclusion, Patients with multiple stones in the common bile duct or with a wide diameter of the common bile duct are more likely to have T-tube placed rather than an internal drainage tube.