Bile duct leaks from the intrahepatic biliary tree: a review of its etiology, incidence, and management. HPB Surg. 2012;2012:752932. [PMID: 22645406 PMCID: PMC3356893 DOI: 10.1155/2012/752932]

MultiCenter Study of Intra-Abdominal Abscess Formation After Major Operative Hepatic Trauma

INTRODUCTION

One of the significant complications of operative liver trauma is intra-abdominal abscesses (IAA). The objective of this study was to determine risk factors associated with postoperative IAA in surgical patients with major operative liver trauma.

METHODS

A retrospective multi-institutional study was performed at 13 Level 1 and Level 2 trauma centers from 2012 to 2021. Adult patients with major liver trauma (grade 3 and higher) requiring operative management were enrolled. Univariate and multivariate analyses were performed.

RESULTS

Three hundred seventy-two patients were included with 21.2% (n = 79/372) developing an IAA. No difference was found for age, gender, injury severity score, liver injury grade, and liver resections in patients between the groups (P > 0.05). Penetrating mechanism of injury (odds ratio (OR) 3.42, 95% confidence interval (CI) 1.54-7.57, P = 0.02), intraoperative massive transfusion protocol (OR 2.43, 95% CI 1.23-4.79, P = 0.01), biloma/bile leak (OR 2.14, 95% CI 1.01-4.53, P = 0.04), hospital length of stay (OR 1.04, 95% CI 1.02-1.06, P < 0.001), and additional intra-abdominal injuries (OR 2.27, 95% CI 1.09-4.72, P = 0.03) were independent risk factors for IAA. Intra-abdominal drains, damage control laparotomy, total units of packed red blood cells, number of days with an open abdomen, total abdominal surgeries, and blood loss during surgery were not found to be associated with a higher risk of IAA.

CONCLUSIONS

Patients with penetrating trauma, massive transfusion protocol activation, longer hospital length of stay, and injuries to other intra-abdominal organs were at higher risk for the development of an IAA following operative liver trauma. Results from this study could help to refine existing guidelines for managing complex operative traumatic liver injuries.

Laparoscopic Duodenum-Preserving Pancreatic Head Resection: A Technique for the Treatment of Benign or Low-Grade Malignant Tumors (10 Cases Report)

Background: Laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) is a surgical procedure that involves the removal of the pancreatic head while aiming to preserve the integrity of the digestive and biliary tracts. With advancements in laparoscopic techniques, the utilization of LDPPHR has been increasing. Methods: We retrospectively analyzed the clinical data of 10 patients who underwent laparoscopic duodenum-preserving total pancreatic head resection (LDPPHR-t) at our center from June 2019 to October 2021. Additionally, we analyzed the use of indocyanine green (ICG) in the initial stage of LDPPHR, based on current reports. Results: LDPPHR-t was successfully performed in all patients. After surgery, 3 patients experienced pancreatic fistula (Grade B), 2 patients experienced bile leakage, and 2 patients experienced postoperative hemorrhage. However, no patient exhibited recurrence or required secondary surgery. Conclusion: LDPPHR-t is a new method for treating benign and low-grade malignant tumors in the pancreatic head. However, it is associated with a high incidence of postoperative complications. In the initial stage, the use of ICG can assist surgeons in identifying the biliary duct and pancreaticoduodenal artery arcade.

Intrahepatic biloma after intraoperative cholangiography

A woman in her 30s presented to the emergency department with a month-long history of postprandial epigastric pain radiating to her back. The diagnosis of cholecystolithiasis and suspected choledocholithiasis was made, and the patient underwent cholecystectomy with cholangiography using standard technique. The surgery was complicated by an intrahepatic bile duct injury attributed to high injection pressure during cholangiography. She developed an intrahepatic collection that was drained and confirmed the diagnosis of biloma. In this case report, we discuss a rare complication of intraoperative cholangiography during laparoscopic cholecystectomy and consider a way to prevent it.

Delayed Extrahepatic Biliary Leak: A Rare Presentation 9 Years Post-Laparoscopic Cholecystectomy

BACKGROUND Biliary leaks are an important cause of the acute abdomen condition, carrying significant levels of morbidity and mortality. They are most commonly the result of acute iatrogenic or blunt trauma, with an identifiable cause. In comparison, spontaneous and delayed biliary leaks are rare phenomena occurring in the absence of recent surgery, endoscopic intervention, or trauma. Here we report the case of a 77-year-old woman presenting with acute abdominal pain, distension, and rigors caused by an extrahepatic biliary leakage 9 years after laparoscopic cholecystectomy. CASE REPORT Laparoscopic hepatobiliary intervention, rather than open surgery, is associated with increased risk of biliary tree injury, including biliary leaks, which typically arise in the immediate postoperative period. This report concerns a 77-year-old woman presenting with acute abdominal pain, distension, and rigors due to extrahepatic biliary leakage 9 years following elective laparoscopic cholecystectomy for cholelithiasis. Computed tomography (CT) showed large-volume abdominopelvic ascites with no obvious source. Intra-abdominal exploration revealed a large biloma with 2 lacerations in the gallbladder fossa. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) found only a vague leak in the extrahepatic biliary tree, with no focal defect or retained biliary calculi. Intra-abdominal drainage and common bile duct (CBD) stenting were performed. Repeat ERCP undertaken 3 months later, however, identified a calculus within the CBD. CONCLUSIONS The patient's rare presentation of biliary leakage 9 years after cholecystectomy raises the question of whether the condition was delayed or spontaneous in nature. The biliary calculus identified 3 months following the leakage raises the possibility of retained biliary calculi.

Assessment of a novel biliary-specific near-infrared fluorescent dye (BL-760) for intraoperative detection of bile ducts and biliary leaks during hepatectomy in a preclinical swine model

OBJECTIVES

Postoperative bile leakage is a common complication of hepatobiliary surgery and frequently requires procedural intervention. Bile-label 760 (BL-760), a novel near-infrared dye, has emerged as a promising tool for identifying biliary structures and leakage, owing to its rapid excretion and strong bile specificity. This study aimed to assess the intraoperative detection of biliary leakage using intravenously administered BL-760 compared with intravenous (IV) and intraductal (ID) indocyanine green (ICG).

MATERIALS AND METHODS

Laparotomy and segmental hepatectomy with vascular control were performed on two 25-30 kg pigs. ID ICG, IV ICG, and IV BL-760 were administered separately, followed by an examination of the liver parenchyma, cut liver edge, and extrahepatic bile ducts for areas of leakage. The duration of intra- and extrahepatic fluorescence detection was assessed, and the target-to-background (TBR) of the bile ducts to the liver parenchyma was quantitatively measured.

RESULTS

In Animal 1, after intraoperative BL-760 injection, three areas of leaking bile were identified within 5 min on the cut liver edge with a TBR of 2.5-3.8 that was not apparent to the naked eye. In contrast, after IV ICG administration, the background parenchymal signal and bleeding obscured the areas of bile leakage. A second dose of BL-760 demonstrated the utility of repeated injections, confirming two of the three previously visualized areas of bile leakage and revealing one previously unseen leak. In Animal 2, neither ID ICG nor IV BL-760 injections showed obvious areas of bile leakage. However, fluorescence signals were observed within the superficial intrahepatic bile ducts after both injections.

CONCLUSIONS

BL-760 enables the rapid intraoperative visualization of small biliary structures and leaks, with the benefits of fast excretion, repeatable intravenous administration, and high-fluorescence TBR in the liver parenchyma. Potential applications include the identification of bile flow in the portal plate, biliary leak or duct injury, and postoperative monitoring of drain output. A thorough assessment of the intraoperative biliary anatomy could limit the need for postoperative drain placement, a possible contributor to severe complications and postoperative bile leak.

Long-term Outcomes of Combined Endoscopic-Radiological Approach for the Management of Complete Transection of the Biliary Tract

BACKGROUND

Complete transection of the main bile duct (CTMD) is a major complication during hepato-bilio-pancreatic (HBP) surgery and is associated with high morbidity and mortality. In recent years, a combined endoscopic-radiological approach (CERA) for minimally invasive treatment of CTMD has been introduced, but evidence on its long-term outcomes is limited. Our aim is to report efficacy, safety, and long-term outcomes of CERA for the management of post-surgical CTMD in a tertiary referral center.

METHODS

All consecutive patients referred for CTMD after HBP surgery between February 2012 and January 2021 were included in this study. CERA was first performed to re-establish biliary tree continuity, and then multiple biliary plastic stents were deployed to guarantee biliary tree reconstruction. Anthropometric, clinical, procedural (endoscopic/radiologic/surgical), and follow-up data were collected and analyzed. Each lesion was classified according to Strasberg classification.

RESULTS

Overall, 60 patients (age 60.5 years, range 28-91), 38 F (61.7%), underwent CERA. Mean interval from surgery to endoscopic treatment was 13.2 days. Mean treatment duration was 526 days (SD ± 415) with a median number of 8 endoscopic sessions (range 1-33). Mean length of the biliary defect was 17.6 mm (SD ± 11.5). Long-term clinical success was achieved in 33/49 (67.3%) of patients. Treatment failure was experienced in 16/49 (32.7%) patients, while after an average follow-up of 41 months, stricture recurrence was observed in 3/36 (8.3%) patients.

CONCLUSIONS

CERA is a minimally invasive and effective technique to re-establish the continuity of the biliary tract after CTMD, achieving permanent restoration in over half of treated patients.

Long-Term Outcomes of Mesohepatectomy for Centrally Located Liver Tumors: Two-Decade Single-Center Experience

BACKGROUND

Mesohepatectomy is a viable treatment option for patients diagnosed with centrally located liver tumors (CLLTs). There are several reports from Eastern centers, but few data are available on this topic from Western centers.

STUDY DESIGN

Data of 128 consecutive patients who underwent mesohepatectomy between September 2000 and September 2020 in our center were analyzed from a prospectively collected database. Patient demographic data, liver tumor characteristics, and intraoperative data were collected. In addition, posthepatectomy bile leakage (PHBL), posthepatectomy hemorrhage (PHH), posthepatectomy liver failure (PHLF), and 90-day mortality after mesohepatectomy were assessed. Long-term outcomes were also reported, and factors that may influence disease-free survival were evaluated.

RESULTS

Of 128 patients, 113 patients (88.3%) had malignant hepatic tumors (primary and metastatic tumors in 41 [32%] and 72 [56.3%] patients, respectively), and 15 patients suffered from benign lesions (11.7%). Among the relevant surgical complications (grade B or C), PHBL was the most common complication after mesohepatectomy and occurred in 11.7% of patients, followed by PHLF in 3.1% of patients and PHH in 2.3% of patients. Only four patients (3.1%) died within 90 days after mesohepatectomy. The 5-year overall survival and overall recurrence (for malignant lesion) rates were 76.5% and 45.1%, respectively.

CONCLUSION

Mesohepatectomy is a safe and feasible surgical treatment with low morbidity and mortality for patients with CLLT. Long-term outcomes can be improved by increased surgical expertise.

Case Report: Usefulness of Drip Infusion Cholangiography With Computed Tomography for the Diagnosis of Biloma in a Dog

Bilomas are encapsulated collections of bile outside or inside the biliary tract within the abdominal cavity. For diagnostic and therapeutic approaches, it is important to identify the origin of bile leaks from the biliary tract. This case report describes the usefulness of drip infusion cholangiography with computed tomography (DIC-CT) for detecting the site of bile leakage in a dog with biloma. A 10-year-old, castrated male Pomeranian dog was referred to our department for gastrointestinal signs. Abdominal ultrasonography detected gallbladder mucocele without evidence of defect on the wall and well-defined anechoic localized fluid accumulation around the right division of the liver. On the other hand, there was only a small amount of ascites in the abdominal cavity. The accumulated fluid collected through abdominocentesis had a bilirubin concentration of 11.4 mg/dl, which was more than twice as high as that in serum (0.4 mg/dl), but had absence of pyogenic bacteria. The DIC-CT with meglumine iotroxate showed two well-defined large fluid collections: one between right medial and lateral lobe and the other between the right lateral lobe and caudate process of caudate lobe. Three-dimensional DIC-CT views that the former was enhanced by the contrast agent and that it communicated with an intrahepatic bile duct of the right lateral lobe. Moreover, the DIC-CT images confirmed communication with each fluid collections. After 6 days of hospitalization, a decrease in the amount of accumulated fluid was confirmed, after which cholecystectomy was performed. The dog was discharged from the hospital without complications. No signs of bile leakage were observed on follow-up imaging on postoperative day 10. According to authors knowledge, this has been the first report to show that DIC-CT can be useful for determining the origin of bile leakage in dogs with bilomas.

Postoperative bile leakage caused by intrahepatic duct injury during right hemicolectomy: A case report

INTRODUCTION

Bile peritonitis is one of the rare complications that can occur after cholecystectomy or hepatectomy. It is associated with high mortality, prolonged hospital stay, and increased cost. We herein report 2 cases of bile leakage as a postoperative complication of right hemicolectomy.

PATIENT CONCERNS

Two patients underwent a right hemicolectomy for colon cancer. Both patients had a history of cholecystectomy, and intrahepatic bile duct dilatation was observed in preoperative imaging study. During surgery, adhesiolysis was performed between the liver and the hepatic flexure of the colon due to adhesion in that area.

DIAGNOSIS

Postoperatively, bile fluid was drained via an intraabdominal drainage tube. Both cases required surgical intervention to explore the origin of the leakage. In both cases, the anastomosis was intact, and the injury of the intrahepatic bile duct just beneath the liver surface was the origin of bile leakage.

INTERVENTIONS

Suture ligation, irrigation, and drainage were performed in both patients.

OUTCOMES

There was no more bile leakage after reoperation, and both patients were discharged in good health after antibiotics treatment.

CONCLUSION

Although very rare, bile leakage due to intrahepatic duct injury can occur after right hemicolectomy in patients with a history of cholecystectomy and intrahepatic duct dilatation. It is necessary to consider the possibility of bile duct injury and anastomotic leakage if bile leakage is suspected after right hemicolectomy.

Fully covered metal biliary stents: A review of the literature

Fully covered self-expandable metal stents (FCSEMS) represent the latest advancement of metal biliary stents used to endoscopically treat a variety of obstructive biliary pathology. A large stent diameter and synthetic covering over the tubular mesh prolong stent patency and reduce risk for tissue hyperplasia and tumor ingrowth. Additionally, FCSEMS can be easily removed. All these features address issues faced by plastic and uncovered metal stents. The purpose of this paper is to comprehensively review the application of FCSEMS in benign and malignant biliary strictures, biliary leak, and post-sphincterotomy bleeding.

Spontaneous Bile Leak in a Patient Without Recent Abdominal Surgery or Trauma

Bile leaks are a rare occurrence most often seen as a complication of cholecystectomy. Other less common etiologies include endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), liver surgery, percutaneous drainage of liver abscesses, living donor hepatectomy, and non-iatrogenic abdominal trauma. In this case study, we present a 67-year-old female with morbid obesity who presented with abdominal pain and was diagnosed with a spontaneous bile leak. She had no history of recent surgery or abdominal trauma. CT revealed that the patient's gallbladder was located in the right lower quadrant, most likely due to mass effect from a large ventral hernia, and possible fluid collection extending from the gallbladder along the surface of the anterior inferior right hepatic lobe. Hepatobiliary iminodiacetic acid (HIDA) was performed due to a concern for cholecystitis. HIDA demonstrated a bile leak in the right upper abdomen of unknown etiology. Initially, there was a concern for gallbladder obstruction. Gastroenterology recommended magnetic resonance cholangiopancreatography (MRCP), however, MRCP was not possible due to the patient's body habitus. The patient had normal liver function tests, was tolerating oral intake, and her abdominal pain resolved, therefore, we became less suspicious of gallbladder obstruction. This case suggests that bile leak should be included in the differential diagnosis for abdominal pain even in patients who have not had recent abdominal surgery or procedures. This case also highlights the unique anatomical finding of a right lower quadrant gallbladder secondary to mass effect from a large ventral hernia.

Delayed cholecystectomy following endoscopic retrograde cholangio-pancreatography is not associated with worse surgical outcomes

BACKGROUND

There is no universal consensus on the optimal timing of cholecystectomy following endoscopic retrograde cholangio-pancreatography (ERCP). This study aims to evaluate the effect of time delay and post-ERCP complications on cholecystectomy outcomes.

MATERIALS AND METHODS

All patients who underwent pre-op ERCP for concurrent cholelithiasis and choledocholithiasis between January 2009 and August 2019 at University Hospitals Plymouth, UK, were included. Patients who underwent single-stage cholecystectomy and common bile duct exploration were excluded from the study. Based on the delay to cholecystectomy, the patients were divided into early (within 2 weeks), intermediate (2-6 weeks) and late (> 6 weeks) groups. The operative outcomes between the three groups were compared.

RESULTS

We included 444 patients in the study, with 62 (14%), 90 (20%) and 292 (66%) patients in the early, intermediate and late groups, respectively. The median duration from ERCP to cholecystectomy was 75 days. There was no statistically significant difference in the conversion-to-open rate, bile leak rate or retained stones between the three groups. The median post-operative hospital stay (PHS) was 2, 2 and 1 day (P = 0.005) in the early, intermediate and late groups, respectively. The readmission rate was significantly more in the delayed group (3.2%, 11.1% and 13.7%; P = 0.05). Patients who suffered post-ERCP complications had a significantly longer PHS (4 vs 1 day, P = 0.001) and had higher conversion-to-open rate (16 vs 4.5%, P = 0.04).

CONCLUSION

Delayed cholecystectomy following ERCP is not associated with worse peri-operative outcomes and can facilitate more day-case surgery. However, early cholecystectomy can significantly reduce readmissions with gallstone-related symptoms and its associated hospital stay. Post-ERCP complications lead to a difficult cholecystectomy.

MRI evaluation of bile duct injuries and other post-cholecystectomy complications

Laparoscopic cholecystectomy is one of the most common procedures performed each year and can be associated with various post-operative complications. Imaging is integral to diagnosis and management of patients with suspected cholecystectomy complications, and a thorough understanding of normal and abnormal biliary anatomy, risk factors for biliary injury, and the spectrum of adverse events is crucial for interpretation of imaging studies. Magnetic resonance cholangiography (MRC) enhanced with hepatobiliary contrast agent is useful in delineating biliary anatomy and pathology following cholecystectomy. In this article, we provide a protocol for contrast-enhanced MR imaging of the biliary tree. We also review the classification and imaging manifestations of post-cholecystectomy bile duct injuries in addition to other complications such as bilomas, retained/dropped gallstones, and vascular injuries.

Precise localization of biliary leak post laparoscopic cholecystectomy with hepatobiliary scintigraphy and adjunct single-photon emission tomography/computed tomography fusion imaging

Laparoscopic cholecystectomy is commonly performed as the treatment of choice for symptomatic gallstone diseases. Bile leak is a potential complication of this procedure and the cystic duct stump is the most common site of leakage. Early diagnosis and treatment of bile leak is crucial in decreasing the morbidity and mortality related to this complication. We present a case of biliary leak following laparoscopic cholecystectomy, diagnosis of active biliary leak, and accurate localization of the site of biliary leak on hepatobiliary scintigraphy and adjunct single-photon emission computed tomography/computed tomography fusion imaging.

Selective Trans-Catheter Coil Embolization of Cystic Duct Stump in Post-Cholecystectomy Bile Leak

BACKGROUND

Percutaneous drainage is a first-line treatment for bilomas developed post-cholecystectomy in the setting of bile leak from the cystic duct stump. Percutaneous drainage is usually followed by surgical or endoscopic treatment to address the leak.

AIMS

This study aimed to evaluate outcome of selective coil embolization of the cystic duct stump via the percutaneously placed drainage catheters in patients with post-cholecystectomy bile leak.

METHODS

Seven patients with persistent bile leak after laparoscopic cholecystectomy who underwent percutaneous catheter placement for biloma/abscess formation in the region of the gallbladder fossa were followed. These patients underwent selective trans-catheter cystic duct stump coil embolization from Feb 2013 to Feb 2019. Procedural management, complications, and success rates were analyzed.

RESULTS

All patients underwent placement of a percutaneous catheter for drainage of biloma formation in the gallbladder fossa post-cholecystectomy. Selective coil embolization of the cystic duct was performed through the existing percutaneous tract on average 3.5 weeks after percutaneous catheter placement, resulting in resolution of the biloma. All bile leaks were immediately closed. None of the patients showed recurrent bile leak or further clinical symptoms. Coil migration to the common bile duct was diagnosed in a single case, after 2.5 years, with no bile leak reported.

CONCLUSIONS

Selective trans-catheter coil embolization of the cystic stump is a feasible and safe procedure, which successfully seals leaking cystic duct stumps and can circumvent the need for repeat surgical or endoscopic intervention in selected patient populations.

Hepatic resection in children: highlighted and revisited steps

Background

Hepatectomy in children deserves exhaustive preoperative and intraoperative tools to define the anatomy, minimize blood loss, and confirm adequacy of liver tissue left. The aim of this study is to report our experience in surgical management of liver tumors.

Results

All liver resections performed in Ain-Shams University Hospital, by the same team, between July 2013 and June 2018 were retrospectively reviewed. Data related to basic demographics, indication for resection, methods of parenchymal resection, blood loss, hospital stay, morbidity, and mortality was collected. The study included 27 patients who underwent different types of hepatectomies. There was a male predominance. Age ranged from 6 months to 13 years. Weight ranged from 5.7 to 33.7 kg. Total operative time ranged from 68 to 322 min, while resection time ranged from 34 to 144 min. Blood loss ranged from 53 to 259 ml. Surgical morbidities included five patients with minor biliary leak, three patients had surgical site infection, and one patient had torsion of the remnant liver necessitating repositioning. Recurrence of the mass was faced in three patients with hepatoblastoma. There were two mortalities; one occurred as a sequela of massive intraoperative bleeding and the other took place due to postoperative hepatic insufficiency.

Conclusion

For a safe hepatectomy, thorough familiarity of the hepatic segmental anatomy together with the various techniques for parenchymal resection and vascular control is fundamental. Complications such as biliary leak and torsion of remnant can be easily avoided by simple measures.

Clinical practice of basin-shaped hepaticojejunostomy following hilar resection of stage III/IV hilar cholangiocarcinoma

Background

Radical surgery for Bismuth type III/IV hilar cholangiocellular carcinoma, which was usually considered unresectable, seems to improve prognosis by increasing the surgical curability rate. However, the dilemma of multiple billiary stumps and high postoperative complication rate caused by hepato-enteric anastomosis has been the main impediment. Thus, we practiced and introduce a new technique called “basin-shaped” hepaticojejunostomy to improve the treatment.

Methods

Thirty-two cases with Bismuth type III/IV hilar cholangiocarcinoma admitted to our department from Aug. 2013 to Dec. 2015 and who underwent hilar resection and resection segment 4(or plus resection segment 1) were reconstructed by “basin-shaped” hepaticojejunostomy. The clinical data were collected and analyzed.

Results

All patients underwent successful R0 high hilar resection following basin-shaped hepaticojejunostomy and were discharged from the hospital without severe postoperative complications. The average operation time for hepato-enteric anastomosis was 42.1 ± 8.5 min. The postoperative bile leakage rate was 3.1% (1/32), and the biliary infection rate was 6.2% (2/32). Within a median follow-up of 25.6 months, none of the patients developed local recurrence around the hepato-enteric anastomosis.

Conclusions

For patients with Bismuth type III/IV hilar cholangiocellular carcinoma who underwent resection segment 4(or plus resection segment 1), basin-shaped hepaticojejunostomy was a safe, simple and valid method for bile duct reconstruction, with a relatively low incidence of postoperative complications.

Minimally invasive donor hepatectomy, are we ready for prime time?

Minimally invasive surgery potentially reduces operative morbidities. However, pure laparoscopic approaches to donor hepatectomy have been limited by technical complexity and concerns over donor safety. Reduced-wound donor hepatectomy, either in the form of a laparoscopic-assisted technique or by utilizing a mini-laparotomy wound, i.e., hybrid approach, has been developed to bridge the transition to pure laparoscopic donor hepatectomy, offering some advantages of minimally invasive surgery. To date, pure laparoscopic donor left lateral sectionectomy has been validated for its safety and advantages and has become the standard in experienced centres. Pure laparoscopic approaches to major left and right liver donation have been reported for their technical feasibility in expert hands. Robotic-assisted donor hepatectomy also appears to be a valuable alternative to pure laparoscopic donor hepatectomy, providing additional ergonomic advantages to the surgeon. Existing reports derive from centres with tremendous experience in both laparoscopic hepatectomy and donor hepatectomy. The complexity of these procedures means an arduous transition from technical feasibility to reproducibility. Donor safety is paramount in living donor liver transplantation. Careful donor selection and adopting standardized techniques allow experienced transplant surgeons to safely accumulate experience and acquire proficiency. An international prospective registry will advance the understanding for the role and safety of pure laparoscopic donor hepatectomy.

Biliary Complications after Hepatic Trauma in Children

Aim of the Study:

In pediatric patients with liver trauma and hemodynamic stability, conservative treatment is acknowledged as the gold standard.

Patients and Methods:

We conducted a retrospective analysis of 116 consecutive pediatric patients (<14-year-old) observed at our institution for closed abdominal trauma from January 2010 to January 2016. Among these, 16 patients (13%) had hepatic trauma Grade II or more, according to Moore liver trauma injury score.

Results:

Only one patient underwent surgery for hemodynamic instability; all others children received conservative treatment according to the American Paediatric Surgical Association guidelines. Three patients had a biliary complication (2, 5%). two patients treated surgically by drainage insertion and one was managed conservatively.

Conclusions:

Biliary complications of liver trauma in children may require aggressive surgical approach in selective patients.

The Echinococcoses: Diagnosis, Clinical Management and Burden of Disease

The echinococcoses are chronic, parasitic diseases that are acquired after ingestion of infective taeniid tapeworm eggs from certain species of the genus Echinococcus. Cystic echinococcosis (CE) occurs worldwide, whereas, alveolar echinococcosis (AE) is restricted to the northern hemisphere, and neotropical echinococcosis (NE) has only been identified in Central and South America. Clinical manifestations and disease courses vary profoundly for the different species of Echinococcus. CE presents as small to large cysts, and has commonly been referred to as 'hydatid disease', or 'hydatidosis'. A structured stage-specific approach to CE management, based on the World Health Organization (WHO) ultrasound classification of liver cysts, is now recommended. Management options include percutaneous sterilization techniques, surgery, drug treatment, a 'watch-and-wait' approach or combinations thereof. In contrast, clinical manifestations associated with AE resemble those of a 'malignant', silently-progressing liver disease, with local tissue infiltration and metastases. Structured care is important for AE management and includes WHO staging, drug therapy and long-term follow-up for at least a decade. NE presents as polycystic or unicystic disease. Clinical characteristics resemble those of AE, and management needs to be structured accordingly. However, to date, only a few hundreds of cases have been reported in the literature. The echinococcoses are often expensive and complicated to treat, and prospective clinical studies are needed to better inform case management decisions.

Precise Localization of a Bile Leak with Hepatobiliary Scintigraphy

Hepatobiliary scintigraphy (HBS) is a widely used modality to diagnose biliary injury. In patients with a history of trauma or surgery, the common presentations of bile leaks on HBS are a progressive collection of radiotracer outside the biliary system. However, the precise localization of a bile leak is usually not conveyed by noninvasive techniques including CT or ultrasound or even HBS. This case study of a patient with liver trauma demonstrates a direct bile leak sign leading to recognition of an exact bile leakage site from the left intrahepatic duct. This diagnosis helped clinicians perform less-invasive management.

Pedicled omental onlay flap for post-traumatic intrahepatic major ductal injury

We report a 5-year-old girl who presented with post traumatic biliary leakage that failed to respond to conservative management for two weeks. Surgical exploration in the third week revealed a partially healed 5 cm long hepatic laceration in the right lobe of the liver. Bile was found leaking through a rent in the major right intra-hepatic duct at the apex of liver laceration. A pedicled onlay omental flap was used to buttress this rent as direct closure was not possible due to friable tissue. The child recovered uneventfully.

A multicentre, randomized clinical trial comparing the Veriset™ haemostatic patch with fibrin sealant for the management of bleeding during hepatic surgery

BACKGROUND

Bleeding during hepatic surgery is associated with prolonged hospitalization and increased morbidity and mortality. The Veriset™ haemostatic patch is a topical haemostat comprised of an absorbable backing made of oxidized cellulose and self-adhesive hydrogel components. It is designed to achieve haemostasis quickly and adhere to tissues without fixation.

METHODS

A prospective, randomized, multicentre, single-blinded study (n = 50) was performed to compare the use of a Veriset™ haemostatic patch with a fibrin sealant patch (TachoSil(®) ) (control) in the management of diffuse bleeding after hepatic surgery. Patients were randomized following the confirmation of diffuse bleeding requiring the use of a topical haemostat. Time to haemostasis was assessed at preset intervals until haemostasis was achieved.

RESULTS

Both groups were similar in comorbidities and procedural techniques. The median time to haemostasis in the group using the Veriset™ haemostatic patch was 1.0 min compared with 3.0 min in the control group (P < 0.001; 3-min minimum application time for the control patch). This result was independent of bleeding severity and surface area. Both products had similar safety profiles and no statistical differences were observed in the occurrence of adverse or device-related events.

CONCLUSIONS

Regardless of bleeding severity or surface area, the Veriset™ haemostatic patch achieved haemostasis in this setting significantly faster than the control device in patients undergoing hepatic resection. It was safe and easy to handle in open hepatic surgery.

Interventional radiology in the management of benign biliary stenoses, biliary leaks and fistulas: a pictorial review

Background

Benign biliary postoperative stenoses and biliary leaks and fistulas usually occur due to injury after laparoscopic cholecystectomy, gastric or hepatic resection, bilio-enteric anastomoses and after liver transplantation. In most of the cases a new surgical intervention is not possible and the percutaneous trans-hepatic approach is of paramount importance in the diagnosis and treatment of the problem. This review aims to highlight the spectrum of percutaneous cholangiographic findings and methods of treatment of postoperative benign biliary stenoses and biliary leaks and fistulas. In the case of stenosis, dilation of the narrow tract is the usually the first approach, whereas in the case of leaks and fistulas bile diversion with drainage is usually attempted in order to seal the fistulous tract. However, a great variety of combination of materials and techniques may be used on a “case-by case” approach

Methods

A selection of cases of benign biliary postoperative stenoses and biliary leaks and fistulas that were managed percutaneously are presented and the most common lines of approach are discussed.

Conclusion

The imaging spectrum of percutaneous treatment of benign biliary postoperative stenoses and biliary leaks and fistulas is presented in order to aid interpretation and management with image guided procedures.

Teaching Points

• Treatment of benign biliary stenosis is performed with cholangioplasty and stents.

• The main goal of fistula treatment is to divert the bile away from the site of bile wall defect.

• Drain collection and tract embolisation are the other options for bile leak percutaneous treatment.