Towards a 'step-up approach' for the treatment of recurrent non-stenotic cholangitis after hepaticojejunostomy: systematic review

BACKGROUND

Recurrent non-stenotic cholangitis (NSC) is a difficult-to-treat complication after hepaticojejunostomy (HJ) leading to multiple hospital admissions. The optimal treatment strategy is unclear as a systematic review is lacking.

METHODS

A systematic review was performed including studies detailing treatment strategies and outcomes for recurrent NSC in patients with a surgical HJ in PubMed, Embase, and Cochrane Library (inception - September 2023). Primary outcome was resolution of NSC as defined by the included studies.

RESULTS

Overall, 72 patients with recurrent NSC after HJ were included from seven retrospective studies. The rate of recurrent NSC (specified in five studies) was 4% (46/1143 HJs). Diagnosis of NSC was mostly made after excluding HJ stenosis and assessing bile reflux. Initial treatment consisted of short-course antibiotics for all patients. Second step treatment consisted of prolonged antibiotic therapy (n = 10, 13.8%). Third step treatment consisted of surgery (n = 9, n = 12.5%); mostly lengthening of the biliary loop. Together, the overall reported resolution-rate of recurrent NSC was 66.6% (n = 48).

CONCLUSION

A 'step-up approach' may be effective in two-thirds of patients with recurrent NSC after HJ, starting with short-course antibiotics, and eventually adding prolonged antibiotic therapy and, ultimately, surgery aimed at preventing intestinal content and food reflux. Prospective studies are needed.

Clinical presentation, management and outcomes of bile duct injuries after laparoscopic cholecystectomy: a 15-year single-center experience in Vietnam

Objectives

To evaluate the clinical presentation, management, and outcomes of bile duct injuries (BDIs) after laparoscopic cholecystectomy (LC).

Methods

This is a case series of 28 patients with BDIs after LC treated at a tertiary hospital in Vietnam during the 2006-2021 period. The BDI's clinical presentations, Strasberg classification types, management methods, and outcomes were reported.

Results

BDIs were diagnosed intraoperatively in 3 (10.7%) patients and postoperatively in 25 (89.3%). The BDI types included Strasberg A (13, 46.4%), D (1, 3.6%), E1 (1, 3.6%), E2 (4, 14.3%), E3 (5, 17.9%), D + E2 (2, 7.1%), and nonclassified (2, 7.1%). Of the postoperative BDIs, the injury manifested as biliary obstruction (18, 72.0%), bile leak (5, 20.0%), and mixed scenarios (2, 8.0%). Regarding diagnostic methods, endoscopic retrograde cholangiopancreatography (ERCP) was more useful in bile leak scenarios, while multislice computed tomography, magnetic resonance cholangiopancreatography, and percutaneous transhepatic cholangiography were more useful in biliary obstruction scenarios. All 28 BDIs were successfully treated. ERCP with stenting was very effective in the majority of Strasberg A BDIs. For more complex BDI types, hepaticocutaneous jejunostomy was a safe and effective approach. The in-hospital morbidities included postoperative pneumonia (2, 10.7%) and biliary-enteric anastomosis leakage (1, 5.4%). There was no cholangitis or anastomotic stenosis during the follow-up after discharge (median 18 months).

Conclusions

The majority of BDIs are type A and diagnosed postoperatively. ERCP is effective for the majority of Strasberg A BDIs. For major and complex BDIs, hepaticocutaneous jejunostomy is a safe and effective approach.

The short- and long-term outcome after the surgical management of common bile duct stones in a tertiary referral hospital

BACKGROUND

The removal of common bile duct stones by endoscopic retrograde cholangiopancreatography (ERCP) shows excellent results with low complication rates and is therefore considered a gold standard. However, in case of stones non-removable by ERCP, surgical extraction is needed. The surgical approach is still controversial and clinical guidelines are missing. This study aims to analyze the outcomes of patients treated with choledochotomy or hepaticojejunostomy for common bile duct stones.

METHODS

All patients who underwent choledochotomy or hepaticojejunostomy for common bile duct stones at a tertiary referral hospital over 11 years were included. The analyzed data contains basic demographics, diagnostics, surgical parameters, length of hospitalization, and morbidity and mortality.

RESULTS

Over the study period, 4375 patients underwent cholecystectomy, and 655 received an ERCP with stone extraction, with 48 of these patients receiving subsequent surgical treatment. ERCP was attempted in 23/30 (77%) of the choledochotomy patients pre/intraoperatively and 11/18 (56%) in hepaticojejunostomy patients. The 30-day major complication rate (Clavien-Dindo > II) was 1/30 (3%) in the choledochotomy group and 2/18 (11%) in the hepaticojejunostomy group. Complications after 30 days occurred in 3/30 (10%) patients and 2/18 (11%), respectively, and no mortality occurred.

CONCLUSION

ERCP should still be considered the gold standard, although due to low short- and long-term morbidity rates, choledochotomy and hepaticojejunostomy represent effective surgical solutions for common bile duct stones.

Successful treatment of postoperative nonobstructive recurrent cholangitis by tract conversion surgery after total pancreatectomy: a case report

BACKGROUND

Postoperative cholangitis is a complication of biliary reconstruction during hepatobiliary pancreatic surgery. Most cases are associated with anastomotic stenosis, but there are also cases of cholangitis without stenosis, and treatment can be difficult, especially in patients with recurrent symptoms. In this report, we describe a case of repeated nonobstructive cholangitis in a patient after total pancreatectomy, in which a good outcome was obtained after performing tract conversion surgery.

CASE PRESENTATION

The patient was a 75-year-old man. He underwent total pancreatectomy for stage IIA cancer of the pancreatic body, hepaticojejunostomy via the posterior colonic route, gastrojejunostomy and Braun anastomosis via the anterior colonic route using the Billroth II method. The patient had a good postoperative course and was receiving adjuvant chemotherapy on an outpatient basis, but he developed his first episode of cholangitis 4 months after surgery. Although conservative treatment with antimicrobial agents was successful, the patient continued to have recurrent biliary cholangitis and was repeatedly admitted and discharged from the hospital. Since stenosis at the anastomosis was suspected, endoscopic observation of the anastomosis was performed using small bowel endoscopy for close examination, but no apparent stenosis was observed. Small bowel imaging indicated a possible influx of contrast medium into the bile duct, and reflux due to food residue was suspected as the cause of cholangitis. Since conservative treatment alone did not suppress the flare-up of symptoms, the decision was made to perform tract conversion surgery for curative purposes. The afferent loop was cut midstream, and jejunojejunostomy was performed downstream. The postoperative course was good, and the patient was discharged on the 10th day after surgery. He is currently an outpatient and has been free of cholangitis symptoms for 4 years without cancer recurrence.

CONCLUSIONS

Although the diagnosis of nonobstructive retrograde cholangitis can be difficult, surgical treatment should be considered in patients with recurrent symptoms and refractory treatment.

Risk Factors for Cholangitis After Pancreatoduodenectomy: A Systematic Review

BACKGROUND

Cholangitis is a late complication after pancreatoduodenectomy with considerable clinical impact and is difficult to treat. The aim of this systematic review was to provide an overview of the literature identifying risk factors for postoperative cholangitis.

METHODS

A systematic search of the databases PUBMED and EMBASE was performed to identify all studies reporting on possible risk factors for cholangitis following pancreatoduodenectomy. Data on patient, peri- and postoperative characteristics were collected. Risk of bias assessment was done according to the methodological index for non-randomized studies (MINORS) criteria.

RESULTS

In total, 464 studies were identified. Eight studies met the inclusion criteria for this analysis. The definition of postoperative cholangitis was inconsistent, with four studies using the Tokyo Guidelines, whereas other studies used different definitions. Data on 26 potential risk factors concerning the patient, peri- and postoperative characteristics were analyzed. Five factors were significantly associated with cholangitis in two or more studies: high body mass index, duration of surgery, benign disease, postoperative pancreatic fistula, and postoperative serum alkaline phosphatase.

CONCLUSION

Multiple potential risk factors for postoperative cholangitis were identified, with large discrepancies between studies. Prospective research, with consensus on the definition, is required to determine the true relevance of these risk factors.

The clinical features of late postoperative cholangitis following pancreaticoduodenectomy brought on by conditions other than cancer recurrence: a single-center retrospective study

Background

Postoperative cholangitis is a late complication of pancreaticoduodenectomy (PD). This study aimed to elucidate the pathogenesis of post-PD cholangitis (PPDC) and explore its optimal treatment.

Methods

We retrospectively analyzed 210 patients who underwent PD at our institute between 2009 and 2018. Patients who underwent follow-up for less than 1 year or had cholangitis caused by cancer recurrence were excluded from the analysis. Diagnostic criteria for cholangitis and its severity were determined based on the classification of acute cholangitis provided by the 2018 Tokyo Guidelines (TG18).

Results

PPDC occurred in 19 (11%) of the 176 included patients. Of these 19 patients, nine experienced more than one episode of cholangitis (total episodes, 36). For 14 patients (74%), the first episode of PPDC occurred within two years after surgery. Based on the TG18, 21 episodes were mild and 15 episodes were moderate; none were severe. Blood culture test results were positive for 16 of 24 episodes. Most patients were hospitalized and treated with intravenous antibiotics (median, seven days). The blood test values improved promptly after treatment was started. Four patients with recurrent cholangitis underwent endoscopic examination, and three of them had anastomotic stenosis of the hepaticojejunostomy. The univariate and multivariate analyses did not indicate any significant predictive factors for PPDC development.

Conclusion

Mild and moderate PPDC occurred and improved with short-term antimicrobial treatment. Temporary reflux into the intrahepatic bile ducts may have been the cause of PPDC while anastomotic stenosis may be involved in recurrent cases.

Progress and Current Limitations of Materials for Artificial Bile Duct Engineering

Bile duct injury (BDI) and bile tract diseases are regarded as prominent challenges in hepatobiliary surgery due to the risk of severe complications. Hepatobiliary, pancreatic, and gastrointestinal surgery can inadvertently cause iatrogenic BDI. The commonly utilized clinical treatment of BDI is biliary-enteric anastomosis. However, removal of the Oddi sphincter, which serves as a valve control over the unidirectional flow of bile to the intestine, can result in complications such as reflux cholangitis, restenosis of the bile duct, and cholangiocarcinoma. Tissue engineering and biomaterials offer alternative approaches for BDI treatment. Reconstruction of mechanically functional and biomimetic structures to replace bile ducts aims to promote the ingrowth of bile duct cells and realize tissue regeneration of bile ducts. Current research on artificial bile ducts has remained within preclinical animal model experiments. As more research shows artificial bile duct replacements achieving effective mechanical and functional prevention of biliary peritonitis caused by bile leakage or obstructive jaundice after bile duct reconstruction, clinical translation of tissue-engineered bile ducts has become a theoretical possibility. This literature review provides a comprehensive collection of published works in relation to three tissue engineering approaches for biomimetic bile duct construction: mechanical support from scaffold materials, cell seeding methods, and the incorporation of biologically active factors to identify the advancements and current limitations of materials and methods for the development of effective artificial bile ducts that promote tissue regeneration.

Complications After Pancreaticoduodenectomy

The most common complications after a pancreaticoduodenectomy are delayed gastric emptying, pancreatic fistulae, hemorrhage, chyle leaks, endocrine and exocrine pancreatic insufficiency, and surgical site infections. Understanding the potential complications and recognizing them are imperative to taking great care of these complex patients. Taking care of these patients postoperatively requires a team approach including experienced nursing staff combined with robust gastroenterology and interventional radiology.

Video review reveals technical factors predictive of biliary stricture and cholangitis after robotic pancreaticoduodenectomy

BACKGROUND

Cholangitis due to anastomotic stricture of the hepaticojejunostomy (HJ) following pancreaticoduodenectomy (PD), while uncommon, adversely affects postoperative quality-of-life. While prior studies have identified patient-related risk factors for these biliary complications, technical risk factors have not been systematically examined. Video review of surgical procedures has helped define technical details predictive of postoperative complications in bariatric and hepato-pancreato-biliary (HPB) surgery. Similarly, the present study utilized video review to identify technical factors associated with cholangitis and anastomotic biliary stricture following robotic PD.

METHODS

This was an observational study. A blinded experienced HPB surgeon reviewed videos of post-learning-curve HJs performed during robotic PD and extracted 20 technical variables. Other demographic and clinical variables were collected from a prospectively maintained database.

RESULTS

241 robotic PD videos were reviewed. 29 (12.0%) developed cholangitis and/or biliary stricture, with a median time-to-event of 189 (IQR 78-365) days. Several clinical and technical factors were independently predictive of cholangitis and/or biliary stricture: preoperative radiotherapy, small duct size (<10 mm diameter), increased distance of the HJ (>10 mm) from the hilar plate, and continuous suturing technique.

CONCLUSION

Post-hoc video review of HJ is a powerful method to predict biliary complications. Moreover, altering specific technical factors might enable surgeons to improve postoperative outcomes.

Benign postoperative hepaticojejunostomy stricture: percutaneous recanalisation using the reverse end of a microwire

AIM

To evaluate the technical feasibility and safety of percutaneous recanalisation of benign postoperative hepaticojejunostomy strictures using the reverse end of a microwire.

MATERIALS AND METHODS

Twenty-one patients with benign postoperative hepaticojejunostomy strictures that had failed to recanalise following management with conventional percutaneous techniques from January 2012 to March 2019 were included in the study. The stricture was punctured by the reverse end of a microwire. Subsequently, serial balloon dilatation and covered stent placement was performed. Technical as well as clinical success, complications, and patency of the hepaticojejunostomy were evaluated.

RESULTS

Technical success was achieved in 19 of 21 (90.5%) patients. The mean number of treatment sessions was 1.2 (range, 1-2). The obstructive symptoms were resolved within 3 days after the procedure in 19 patients (100%). There were no major complications. The 1-year and 3-year patency rates were 76.9% and 61.5%, respectively.

CONCLUSION

Percutaneous recanalisation using the reverse end of a microwire is technically feasible and safe in the treatment of benign postoperative hepaticojejunostomy strictures. This technique is useful when the conventional percutaneous technique cannot be used to cross the stricture.

Cholangitis following biliary-enteric anastomosis: A systematic review and meta-analysis

BACKGROUND

Cholangitis is a serious biliary complication following biliary-enteric anastomosis (BEA). However, the rate of cholangitis in the postoperative period and its associated risk factors are inconclusive. The objective of this systematic review and meta-analysis was to assess the onset and risk factors of cholangitis after biliary-enteric reconstruction in literature.

METHODS

MEDLINE, EMBASE, and Cochrane databases were searched systematically to identify studies reporting about cholangitis following biliary-enteric anastomosis. Meta-analyses were performed for risk factors using random effects model with odds ratio (OR) and 95% confidence interval (95 %CI) as effect measures. Study quality was assessed by the MINORS (methodological index for non-randomized studies) criteria.

RESULTS

28 studies involving 6904 patients were included in the study. The pooled rate for postoperative cholangitis (POC) was 10% (95 %CI: 8 %-13%) with studies reporting about an early- and late-onset of cholangitis. Male sex (OR 2.08; 95 %CI: 1.33-3.24; P = 0.001), postoperative hepatolithiasis (OR 137.19; 95 %CI: 29.00-648.97; P < 0.001) and postoperative anastomotic stricture (OR 178.29; 95 %CI: 68.64-463.11; P < 0.001) were associated with a higher risk of a late-onset of POC with a pooled rate of 8% (95 %CI: 6 %-11%) after a median time interval of 12 months. The quality of the included studies was low to moderate.

CONCLUSION

Cholangitis is a frequent complication after BEA. Consensus definition and prospective trials are required to assess optimal therapeutic strategies. We proposed a standardized definition and grading of POC to enable comparisons between future studies.

Biliary leakage following pancreaticoduodenectomy: Prevalence, risk factors and management

BACKGROUND

Few studies investigated biliary leakage after pancreaticoduodenectomy (PD) especially when compared to postoperative pancreatic fistula (POPF). This study was to determine the incidence of biliary leakage after PD, predisposing factors of biliary leakage, and its management.

METHODS

We retrospectively studied all patients who underwent PD from January 2008 to December 2017 at Gastrointestinal Surgery Center, Mansoura University, Egypt. According to occurrence of postoperative biliary leakage, patients were divided into two groups. Group (1) included patients who developed biliary leakage and group (2) included patients without identified biliary leakage. The preoperative data, operative details, and postoperative morbidity and mortality were analyzed.

RESULTS

The study included 555 patients. Forty-four patients (7.9%) developed biliary leakage. Ten patients (1.8%) had concomitant POPF. Multivariate analysis identified obesity and time needed for hepaticojejunostomy reconstruction as independent risk factors of biliary leakage, and no history of preoperative endoscopic retrograde cholangiopancreatiography (ERCP) as protective factor. Biliary leakage from hepaticojejunostomy after PD leads to a significant increase in development of delayed gastric emptying, and wound infection. The median hospital stay and time to resume oral intake were significantly greater in the biliary leakage group. Non-surgical management was needed in 40 patients (90.9%). Only 4 patients (9.1%) required re-exploration due to biliary peritonitis and associated POPF. The mortality rate in the biliary leakage group was significantly higher than that of the non-biliary leakage group (6.8% vs 3.9%, P = 0.05).

CONCLUSIONS

Obesity and time needed for hepaticojejunostomy reconstruction are independent risk factors of biliary leakage, and no history of preoperative ERCP is protective factor. Biliary leakage increases the risk of morbidity and mortality especially if concomitant with POPF. However, biliary leakage can be conservatively managed in majority of cases.

Management of delayed stenosis of pancreatico-enteric anastomosis following pancreatoduodenectomy

Stenosis of the pancreatico-enteric anastomosis following pancreatoduodenectomy (PD), a late post-operative complication that is seen mainly after PD for diseases with good prognosis, has been reported in less than 3% of cases in the literature. Most often asymptomatic, pancreatic-enteric anastomotic stenosis can lead to pancreatitis, pain or pancreatic insufficiency. Symptomatic stenosis is difficult to treat and its management is not standardized. Magnetic resonance cholangiopancreatography is the best investigation to confirm the diagnosis of stenosis. The Endoscopic UltraSonography (EUS) « rendezvous » technique, associating an endoscopic approach and EUS-guided puncture of the main pancreatic duct, has been available since 2010. Of note, however, the failure rate of the EUS series is as high as 25%, leading to repeat procedures. Surgical reconstruction of the anastomosis has been reported with good results in terms of morbidity. Surgical re-do of the pancreatico-enteric anastomosis for stenosis following PD carries a low risk of pancreatic fistula (around 5%) and an overall morbidity rate of around 20%.

Predictive factors of late cholangitis in patients undergoing pancreaticoduodenectomy

Background

Because the survival rate for patients experiencing late complications after pancreaticoduodenectomy (PD) is increasing, late complications should receive as much attention as early complications do.

Methods

Between April 2007 and August 2016, 133 patients underwent PD at our institution. We analyzed their cases to determine the predictors of late cholangitis after PD.

Results

Of the 133 patients, 28 (21.1%) were diagnosed with postoperative cholangitis. A multivariate analysis showed that abnormal postoperative values of alkaline phosphatase were independently associated with postoperative cholangitis (odds ratio, 3.81; 95% confidence interval, 1.519–9.553; P = 0.004). The optimal cut-off value for postoperative alkaline phosphatase calculated from the receiver operating characteristic curve was 410 IU/L (sensitivity, 76.2%; specificity, 67.9%; area under the curve, 0.73). A univariate analysis to identify risk factors showed that pneumobilia was significantly related to a postoperative alkaline phosphatase value ≥ 410 IU/L (P = 0.041).

Conclusion

This study suggests that an alkaline phosphatase level ≥ 410 IU/L is a predictor of late postoperative cholangitis. In addition, pneumobilia is also related to the postoperative alkaline phosphatase level. Therefore, alkaline phosphatase levels should be carefully monitored in patients with postoperative pneumobilia in the late postoperative course.