A ten-year study on non-surgical treatment of postoperative bile leakage

Application of three-dimensional visualization technology in early surgical repair of bile duct injury during laparoscopic cholecystectomy

OBJECTIVE

This study aimed to explore the application value of three-dimensional (3D) visualization technology in the early surgical repair of bile duct injury during laparoscopic cholecystectomy (LC).

METHODS

A retrospective analysis was conducted on the clinical data of 15 patients who underwent early surgical repair of bile duct injury during LC with the assistance of 3D visualization technology at the Hepatobiliary Surgery Department of Ningxia Hui Autonomous Region People's Hospital from January 2019 to December 2022. Postoperative efficacy and long-term follow-up outcomes were summarized.

RESULTS

Before the repair surgery, 15 cases of bile duct injury during LC were evaluated using 3D visualization technology according to the Strasberg-Bismuth classification: 2 cases of type C, 4 of type E1, 3 of type E2, 3 of type E3, and 3 of type E4. Intraoperative findings were consistent with the 3D visualization reconstruction results, and all patients successfully underwent hepaticojejunostomy using Roux-en-Y anastomosis guided by the 3D visualization navigation. The time interval between LC and bile duct repair surgery ranged from 5 to 28 (14.2 ± 9.7) days. The surgical time was between 120 and 190 (156.40 ± 23.92) min, and estimated blood loss ranged from 80 to 250 (119.66 ± 47.60) mL. The length of hospital stay ranged from 12 to 25 days (median: 16 days). One patient experienced mild bile leakage after the operation, which healed with conservative treatment. All patients were followed up for 12-56 months (median: 34 months) without any loss to follow-up. During the follow-up period, no complications, such as anastomotic stricture or stone formation, were observed.

CONCLUSION

The application of 3D visualization technology for preoperative evaluation and intraoperative navigation can accurately and effectively facilitate early surgical repair of bile duct injury during LC and has clinical value for promotion and application.

Surgical treatment of postoperative intractable bile leakage after liver tumor surgery in children

Aim

To summarize systematically our six-year experience in the surgical treatment of postoperative bile leakage after liver tumor surgery in children, and explore its reoperation approach and treatment effect.

Methods

The clinical data of 6 patients with postoperative bile leakage cured by surgery from January 2016 to January 2022 were reviewed retrospectively.

Results

Among the six pediatric patients with postoperative bile leakage cured by surgery, four were male (67%) and two were female (33%). All patients underwent complex segmentectomy. The median time to bile leakage was 14 days (range, 10 to 32), and the daily drainage volume was stable from 170 ml to 530 ml per day. After conservative treatment failed, four patients received biliary-enteric anastomosis (patients 1, 3, 4, and 6), and two patients received bilio-cholecyst anastomosis (patients 2 and 5). All six patients were successfully treated with reoperation, and five patients were alive and without recurrence, while one patient was lost to follow-up due to abandoned treatment.

Conclusion

Our study suggests that surgery is a reliable and effective treatment for postoperative intractable bile leakage in children undergoing complex segmentectomy. Bilioenteric anastomosis is the most common technique for bile leakage, and bilio-cholecyst anastomosis is a feasible and effective surgical approach. These findings have important implications for the management of postoperative complications in pediatric patients undergoing complex segmentectomy.

Successful application of indocyanine green fluorescent imaging for the non-invasive detection of postoperative bile leakage

There is a lack of a simple and reliable method for the diagnosis of postoperative bile leakage. ICG is a water-soluble fluorescent contrast agent. After intravenous injection of ICG, ICG is eventually excreted only through the biliary tract system into the intestines. It is highly sensitive, stable and nonradioactive, and these characteristics provide a theoretical basis for using ICG to diagnose postoperative bile leakage. Two patients with postoperative bile leakage were successfully identified using indocyanine green fluorescent imaging for the first time, suggesting its potential to be a convenient and reliable method for the diagnosis of postoperative bile leakage.

Management of Biliary Complications in Liver Transplant Recipients

Biliary complications are often referred to as the Achilles' heel of liver transplantation (LT). The most common of these complications include strictures, and leaks. Prompt diagnosis and management is key for preservation of the transplanted organ. Unfortunately, a number of factors can lead to delays in diagnosis and make adequate treatment a challenge. Innovations in advanced endoscopic techniques have increased non-surgical options for these complications and in many cases is the preferred approach.

Development and validation of the bile leakage grading criterion in patients following Roux-en-Y hepaticojejunostomy

OBJECTIVE

The present research aimed to propose a severity grading criterion for bile leakage in pediatric patients after Roux-en-Y hepaticojejunostomy for choledochal cysts.

SUMMARY BACKGROUND DATA

Despite a bile leakage classification system from the International Study Group of Liver Surgery (ISGLS) has been developed, a commonly used grading system for pediatric patients after Roux-en-Y hepaticojejunostomy has not yet been established.

METHODS

A review of clinical, laboratory, and ultrasonographic parameters were used to develop a grading system for classifying the severity of bile leakage. A total of 267 patients with bile leakage were retrospectively assessed to review the system.

RESULTS

We developed a grading system for bile leakage severity for use in pediatric patients following Roux-en-Y hepaticojejunostomy. By applying the criteria to 267 patients, grade I, II, or III bile leakage was determined in 103 patients (8.7%), 115 patients (9.8%), and 49 patients (4.2%) patients, respectively. The most severe bile leakage grade (grade III), was associated with significantly higher γ-glutamyl transpeptidase and amylase levels, greater drain fluid output, more intensive care unit (ICU) admissions, and longer postoperative hospital stay. Interestingly, patients with grade II leakage who underwent reoperation had significantly more ICU admissions, longer postoperative hospital stays (p < 0.05), and higher overall hospitalization cost (p < 0.05) compared with those who underwent conservation management. Of the patients with bile duct stricture and common bile duct (CBD) stones, there were no differences among the different grades of postoperative bile leakage.

CONCLUSIONS

The proposed bile leakage criteria may optimize objective diagnosis and therapeutic modalities.

Case Report: Biloma gastrostomy after failed sonogram-guided percutaneous aspiration, pigtail catheter insertion and surgical drainage

Bilomas are rare abnormal extrabiliary accumulation of bile.  This can be either intrahepatic or extrahepatic following traumatic or spontaneous rupture of the biliary tree. The commonest causes of biloma are surgery, percutaneous transhepatic cholangiography, percutaneous transhepatic biliary drainage, transcatheter arterial embolization and abdominal trauma. We report here a 15 year old patient whom we followed for over 10 years. His chief complaints were right hypochondriac pain, loss of appetite and vomiting. Initial clinical presentation, sonographic as well as laboratory findings suggested a liver abscess, which was drained, but the definitive diagnosis of biloma was entertained after sonographically guided percutaneous aspirations and percutaneous transhepatic cholangiography 7 years later. We also discuss the role of imaging and surgical challenges encountered that culminated into bilomo-gastrostomy. The patient is now enjoying a peaceful life.

The difficult hepaticojejunostomy after pancreatic head resection: reconstruction with a T tube

BACKGROUND

After pancreatic head resection, bile leaks from a difficult hepaticojejunostomy secondary to a small or fragile common hepatic duct may be reduced by a T tube at the side of the anastomosis.

METHODS

A retrospective analysis of patients who underwent a difficult hepaticojejunostomy without or with a T tube was performed.

RESULTS

In 48% (55/114) of patients, a T tube was placed at the side of the hepaticojejunostomy; 52% (59/114) did not have a T tube. Bile leaks occurred in 12% (14/114) (9% [5/55] in patients with a T tube vs 15% [9/59] without a T tube, P = .316). Bile leaks were associated with mortality, abscess formation, hemorrhage, and sepsis. Seven percent (8/114) of patients required revisional laparotomy (2% [1/55] with a T tube vs 12% [7/59] without a T tube, P = .036). Mortality was not different between the groups. Minor T-tube-associated complications occurred in 15% (8/55) without major complications.

CONCLUSIONS

Augmentation of anastomosis with a T tube cannot prevent biliary leakage but does reduce the severity of bile leaks, resulting in less reoperations.

Endoscopic management of biliary complications after partial liver resection in children

BACKGROUND

Biliary complications after liver surgery are difficult to manage. Endoscopic retrograde cholangiopancreatography (ERCP) with stenting of the common bile duct is not commonly practiced in children for this purpose. The aim of this retrospective review is to evaluate the role of ERCP as both a diagnostic and a therapeutic tool in the management of biliary complications after liver resection in children.

PATIENTS AND METHODS

The charts of all patients from 0 to 18 years old who underwent partial liver resection in a tertiary children's hospital in Amsterdam, the Netherlands, between 2000 and 2010 were retrospectively reviewed.

RESULTS

Forty-five children (median age: 3.6 years, range: 2 months-17 years) underwent partial liver resection. Post-operative biliary complications occurred in 13 children. Ten patients were suffering from bile leakage. Eight of them underwent ERCP with stent placement after which leakage stopped in 5 patients. Three patients presented with a post-operative biliary tract stricture. ERCP with dilation and stent placement was performed in 2 of them, which solved the problem in one patient. ERCP demonstrated the nature (bile leak and/or biliary tract stricture(s)), extent, and location of the lesion in 8 of 10 children. There were no serious procedure related complications. Rescue procedures in the other patients included hepaticojejunostomy and liver transplant.

CONCLUSION

ERCP with stenting of the common bile duct has a diagnostic and therapeutic role in the management of bile leaks after partial liver resection in children. The value of ERCP in the management of a stricture of the biliary tract is less conclusive.

Chemoembolization with drug-eluting beads complicated by intrahepatic biloma

Chemoembolization with drug-eluting beads is a type of locoregional therapy currently being used for the treatment of hepatocellular carcinoma and metastatic disease to the liver. This treatment has proven effectiveness in controlling tumor growth, extending survival time, and improving quality of life. Chemoembolization with drug-eluting beads have been shown to be safe, but like any other invasive procedure, can have associated complications. The authors present a case of intrahepatic biloma formation occurring as a result of treatment with drug-eluting beads.

EUS-guided drainage of bilomas: a new alternative?

BACKGROUND

Bilomas have traditionally been treated by either percutaneous drainage or surgery. However, percutaneous drainage is associated with discomfort and infection, whereas surgery, which is usually reserved for refractory cases, has high morbidity and mortality rates. Recently, endoscopic drainage of bilomas adjacent to the GI lumen has been reported in isolated reports.

OBJECTIVE

We analyzed our 4 years' experience with this innovative technique.

DESIGN

Patients with symptomatic bilomas were offered EUS-guided drainage and were followed up prospectively for clinical and radiologic responses.

SETTING

Tertiary care center with long-standing experience in EUS-guided drainage.

PATIENTS

A total of 5 patients underwent EUS-guided transenteric drainage of symptomatic bilomas.

INTERVENTION

The technique included transenteric EUS-guided puncture, placement of a guidewire into the biloma, and creation of an enteral-biloma fistula with placement of a plastic endoprosthesis after balloon dilation. In 4 cases, the stents were removed at a mean of 6.8 +/- 4.3 weeks. In one patient with malignancy, the stent was left in place for palliation.

MAIN OUTCOME MEASUREMENTS

Efficacy and safety of EUS-guided drainage of bilomas.

RESULTS

EUS-guided transenteric biloma drainage was successfully performed in 5 patients without any significant morbidity. Biloma resolution was confirmed in all 5 patients, and none of the 4 patients relapsed after stent removal (mean follow-up of 12.8 +/- 6.1 months).

CONCLUSIONS

EUS-guided drainage of bilomas is technically feasible, appears safe, and provides an attractive alternative to percutaneous or surgical drainage.

Retrievable Biliary Stent-Graft Management of Refractory Postoperative Bile Leakage

The authors report a case of a successful outcome after retrievable biliary stent-graft management in a patient with refractory postoperative bile leakage. A 52-year-old man who underwent a Whipple operation presented with postoperative bile leakage. A percutaneous transhepatic biliary drainage (PTBD) catheter remained from the operation, and bile leakage persisted after 7 days of drainage with the catheter. A retrievable biliary stent-graft was placed; it was removed 14 days later. Cholangiography indicated patency of the anastomosis without contrast medium leakage, and the PTBD catheter was removed. There were no procedural-related complications.

Percutaneous transhepatic cholangiodrainage as rescue therapy for symptomatic biliary leakage without biliary tract dilation after major surgery

Symptomatic biliary leakage following major upper abdominal surgery is a severe complication resulting in increased morbidity and mortality. Treatment options usually include either endoscopic intervention or surgical revision. These options may be burdened by a high perioperative risk for the patient (e.g., patients with severe disease) or simply may not be possible (e.g., nonpreserved gastroduodenal passage). In the past, percutaneous transhepatic cholangiodrainage did only seem to be a viable option for patients with dilated bile ducts. Here, we present our experience in a consecutive series of patients with symptomatic biliary leakage following major upper abdominal surgery and without dilation of the biliary system that underwent percutaneous transhepatic cholangiodrainage. Percutaneous transhepatic cholangiodrainage was feasible in 15 of 18 patients (83.3%). The procedure was technically not possible in three patients (16.7%). In 10 of the 15 patients (66.6%) with feasible percutaneous transhepatic cholangiodrainage, biliary leakage was definitely controlled without the need for surgical revision. Depending on the experience with the interventional procedure, percutaneous transhepatic cholangiodrainage should be considered as an alternative for treatment of symptomatic biliary leakage instead of immediate reoperation.

Imaging-Guided Catheter Drainage of Abdominal Collections with Fistulous Pancreaticobiliary Communication

OBJECTIVE

Our aim was to study the success of percutaneous imaging-guided catheter drainage of abdominal collections with documented fistulous pancreaticobiliary communication.

MATERIALS AND METHODS

Fifty-seven patients (age range, 23-88 years) with abdominal collections who underwent imaging-guided catheter drainage were included in this retrospective study. These collections showed communication with either the pancreatic duct (n = 15) or the biliary duct (n = 42) on imaging. The imaging guidance included CT (n = 40), sonography (n = 17), and fluoroscopy (n = 4), either alone or in combination. The success of catheter drainage was described as resolution of the collection on follow-up imaging and clinical improvement. Other treatments directed toward management of leaks or collections were also recorded.

RESULTS

The success rates of catheter drainage for abdominal collections with biliary and pancreatic ductal communication were 93% (39/42) and 67% (10/15), respectively. The difference was statistically significant (p = 0.01). The three complications seen in this study were pneumothorax in one patient, bowel perforation in one, and death in one. The drainage catheter was upsized in five patients and an additional catheter was needed in nine patients.

CONCLUSION

Imaging-guided catheter drainage is a clinically useful option for drainage of abdominal collections that have pancreaticobiliary communications. The success rate is significantly better for collections with biliary communication than for those with pancreatic communication.

Assessment of early biliary complications after orthotopic liver transplantation and their relationship to the technique of biliary reconstruction

INTRODUCTION

Biliary complications are known as the weak point of liver transplantation. Their occurrence can be related to the practice of drainage of the biliary anastomosis, the routine use of which was abandoned in June 2004. The aim of the study was to assess the incidence and type of biliary complications following orthotopic liver transplantation in relation to the technique of biliary anastomosis.

MATERIAL AND METHODS

We compared the results of two groups of adult liver transplant recipients: group I, recent 50 transplantations with biliary drainage (25 women: 25 men of age range: 17 to 63 years), and group II, first 50 transplantations without drainage (19 women and 31 men of age range, 20 to 65 years). We examined the problem of biliary complications and their influence on the further management of the patients. In both groups the main indications for transplantation were various types of cirrhosis as well as cholestatic diseases. In the majority of cases (n = 86) an end-to-end common bile duct anastomosis was performed and in 14 cases, hepaticojejunal anastomosis.

RESULTS

In group I, biliary complications requiring surgical or endoscopic intervention occurred in 10 (20%) recipients. In one case, biliary complications resulted in the need for retransplantation. In group II, biliary complications occurred in only four (8%) patients, none of which caused organ loss.

CONCLUSION

Cessation of biliary anastomosis drainage has reduced the occurrence of early biliary complications following orthotopic liver transplantation.

Intérêt de l’IRM avec perfusion de mangafodipir trisodium dans la détection des fuites biliaires

PURPOSE

To assess the value of contrast-enhanced magnetic resonance cholangiography with Teslascan perfusion for the detection and localization of trauma-induced and postoperative bile leaks.

MATERIALS AND METHODS

Between October 2002 and December 2004, 7 patients with suspected bile duct leaks after trauma (n = 2) or surgery (n = 5) requiring morphological evaluation were included. MRI examination included single shot fast spin- echo T2 weighted and gradient echo T1 weighted images prior to and 112 minutes in average after IV administration of mangafodipir trisodium. The results of contrast enhanced MR cholangiography were correlated to surgery (n = 3), clinical course (n = 3) and percutaneous drainage (n = 1).

RESULTS

Mangafodipir trisodium-enhanced imaging showed extravasated Teslascan in collections in 6 patients (86%) whereas the combination of T2 weighted images and mangafodipir trisodium enhanced images revealed biliary collections in 7 patients (100%). The fistula between bile duct and collection was visualized in 4 patients (57%) before mangafodipir trisodium perfusion and in 3 patients (43%) after injection. In one patient the fistula was visible only after injection. Combination of both pre- and post injection MR correctly depicted the origin of bile leak in 5 cases (71%).

CONCLUSION

Mangafodipir trisodium-enhanced magnetic resonance cholangiography is a non invasive technique that can successfully detect the presence of bile duct leaks. The combination of T2 weighted MR cholangiography and mangafodipir trisodium-enhanced T1 weighted MR cholangiography increases the sensitivity in detection and localization of the site of bile leak.

[Acute post-cholecystitis bilioma. Based on two cases]

A bilioma is an encapsulated collection of bile outside the biliary tree, which, in general, appears after a laceration in the biliary tract secondary to traumatism or to an iatrogenic lesion. Rarely, it occurs without a traumatic factor. We present two cases of bilioma as a complication of acute alithiasic cholecystitis. A review of the literature and the role of the ultrasonography in the diagnosis and management of biliomas is performed.

N/A

N/A

Hepatic Duct Confluence Injury in Blunt Abdominal Trauma: Case Report and Synopsis on Management

Injuries of the extra hepatic biliary tree following blunt trauma to the abdomen are rare. We present here a case of injury to the confluence of the hepatic ducts and a brief synopsis on diagnosis and management of blunt injury to the extrahepatic biliary system.