Bile Leakage Test Research Articles

White test versus conventional saline test in detecting intra-operative bile leakage in liver resection

Abstract Background Hepatic surgery will be always one of the most challenging surgical procedures due to its anatomical and pathophysiologic varieties. Various problems may complicate the post-operative course. Bile leak remains a serious complication after hepatectomy. Bile leaks can significantly impact morbidity, mortality, and cost of treatment. Bile leak increases risk of sepsis, need for further intervention, either radiological or return to theatre, prolongs duration of intensive care unit and hospital stay, and can precipitate liver failure and death. Objective To assess the post-operative bile leak complication after using white test versus conventional saline test Patients and Methods A prospective study on 50 Hepatectomy cases divided into two groups, the first group consist of 25 cases using white test and the second group consist of 25 cases using conventional saline test from January 2019 to January 2020, at Hepatobiliary unit of the general surgery department of Ain Shams university hospitals. Results The White test has clear advantages in comparison with other bile leakage tests: it precisely detects bile leakages, regardless of size; it does not stain the resection surface, allowing it to be washed off and repeated ad infinitum; and it is safe, quick, and inexpensive. The white test is a feasible and sensitive bile leakage test with no obvious disadvantages. It could be a possible standardized method to prevent bile leakage in major liver resection. Conclusion Now after we discussed our study and reviewed other opinions discussing the optimal methods for intraoperative bile leakage testing, we have now settled on White test using fat emulsion solution to be best of all tests.

Bronchobiliary Fistula due to Hydatid Liver Cyst and Role of Bile Leakage Test during Surgical Treatment

Bronchobiliary Fistula due to Hydatid Liver Cyst and Role of Bile Leakage Test during Surgical Treatment

The utility of 5-aminolevulinic acid-mediated photodynamic diagnosis in the detection of intraoperative bile leakage

PurposeThe purpose of this retrospective study was to evaluate the utility of the new intraoperative bile leakage test as a preventive measure of postoperative bile leakage. Method737 patients were retrospectively analyzed with respect to the management of intra- and post-operative bile leakage. ResultsNine (8.3%) of 109 patients evaluated using conventional white light fluorescent imaging were recognized as having intra-operative bile leakage. However, performance of 5-aminolevulinic acid (5-ALA)-mediated PDD detected bile leakage intraoperatively not only in these 9 patients, but also in an additional 6 patients, such that ‘red fluorescence’ at the cut surface of the liver, was visualized in a total of 15 patients. The postoperative courses of most patients were uneventful, and postoperative bile leakages occurred in only one (0.9%) patient. Conclusion5-ALA fluorescence imaging may be needed to prevent postoperative bile leakage in patients at high risk for this surgical complication after hepatic resection.

Role of bile leakage test in preventing bile leakage during partial liver resection

To evaluate the value of an intraoperative bile leakage test during liver resection in the prevention of bile leakage after hepatic resection. A sterile fat emulsion was injected through the duct of gallbladder among patients from the treatment group so as to observe leakage status on hepatic resection plane; the leakage points were timely handled. The hepatic resection plane was treated with conventional methods among patients from the control group. The incidence rates of bile leakage and other complications were analyzed between two groups. Two (4%) of 53 patients from the treatment group had bile leakage versus 8 (15%) of 54 patients from the control group. Significant differences existed between two groups in terms of the incidence of bile leakage (P 0.05). An intraoperative bile leakage test is sensitive in detecting interoperative bile leaks and can effectively prevent bile leakage after hepatic resection. And it does not increase the likelihood of other complications. Key words: Postoperative complications, bile leakage; Hepatectomy

Randomized Controlled Trial of the Intraoperative Bile Leakage Test in Preventing Bile Leakage after Hepatic Resection

Aim: To evaluate the value of an intraoperative bile leakage test during liver resection in preventing bile leakage after hepatic resection. Methods: A sterile fat emulsion was injected through the duct of the gallbladder among patients from the treatment group so as to observe leakage status on the hepatic resection plane; the leakage points were dealt with in time. The hepatic resection plane was treated using conventional methods among patients from the control group. Results: The incidence rates of the bile leakage and other complications in the two groups were analyzed in this study. Two (3.7%) of the 53 patients from the treatment group had bile leakage, and 8 (14.8%) of the 54 patients from the control group had bile leakage. There were significant differences between the two groups (p < 0.05) in terms of the incidence of the bile leakage. With regard to the incidence of other complications, there were no significant differences between the two groups (p > 0.05). Conclusions: An intraoperative bile leakage test appears to be sensitive in detecting interoperative bile leaks and can effectively prevent bile leakage after hepatic resection, and it does not increase the likelihood of other complications.

Bile leakage test in liver resection: A systematic review and meta-analysis

To assess systematically the safety and efficacy of bile leakage test in liver resection. Randomized controlled trials and controlled clinical trials involving the bile leakage test were included in a systematic literature search. Two authors independently assessed the studies for inclusion and extracted the data. A meta-analysis was conducted to estimate postoperative bile leakage, intraoperative positive bile leakage, and complications. We used either the fixed-effects or random-effects model. Eight studies involving a total of 1253 patients were included and they all involved the bile leakage test in liver resection. The bile leakage test group was associated with a significant reduction in bile leakage compared with the non-bile leakage test group (RR = 0.39, 95%CI: 0.23-0.67; I (2) = 3%). The white test had superiority for detection of intraoperative bile leakage compared with the saline solution test (RR = 2.38, 95%CI: 1.24-4.56, P = 0.009). No significant intergroup differences were observed in total number of complications, ileus, liver failure, intraperitoneal hemorrhage, pulmonary disorder, abdominal infection, and wound infection. The bile leakage test reduced postoperative bile leakage and did not increase incidence of complications. Fat emulsion is the best choice of solution for the test.

Evaluation of the White Test for the Intraoperative Detection of Bile Leakage

We assess whether the White test is better than the conventional bile leakage test for the intraoperative detection of bile leakage in hepatectomized patients. This study included 30 patients who received elective liver resection. Both the conventional bile leakage test (injecting an isotonic sodium chloride solution through the cystic duct) and the White test (injecting a fat emulsion solution through the cystic duct) were carried out in the same patients. The detection of bile leakage was compared between the conventional method and the White test. A bile leak was demonstrated in 8 patients (26.7%) by the conventional method and in 19 patients (63.3%) by the White test. In addition, the White test detected a significantly higher number of bile leakage sites compared with the conventional method (Wilcoxon signed-rank test; P < 0.001). The White test is better than the conventional test for the intraoperative detection of bile leakage. Based on our study, we recommend that surgeons investigating bile leakage sites during liver resections should use the White test instead of the conventional bile leakage test.

Leakage tests reduce the frequency of biliary fistulas following hydatid liver cyst surgery

BACKGROUND AND AIM:Biliary fistulas are the most common morbidity (8.2-26%) following hydatid liver surgery. The aim of our study was to reduce the incidence of postoperative biliary fistulas after the suturing of cystobiliary communications by applying a bile leakage test.PATIENTS AND METHODS:A total of 133 hydatid liver cysts from 93 patients were divided into two groups, according to whether the test was performed. Tests were performed on 56 cysts from 34 patients, and the remaining 77 cysts from 59 patients were treated without the test. In both groups, all visible biliary orifices in the cysts were suture ligated, and drains were placed in all cysts. The visibility of the biliary orifices and postoperative biliary drainage through the drains were recorded. Patients in both groups were also compared with respect to the number of days living with the drains, the length of the hospital stay, and secondary interventions related to biliary complications.RESULTS:Biliary orifices were more visible in the tested cysts (13% vs. 48%; P <0.001). Fewer biliary complications occurred in the tested patients (8.8% vs. 27.7%, P = 0.033). The mean drain removal time (4.1±3.3 days vs. 6.8±8.9 days, P<0.05) and the length of the hospital stay (6.7±2.7 days vs. 9.7±6.3 days, P<0.01) were shorter for the tested patients. None of the patients in the test group required postoperative Endoscopic retrograde cholangiopancreaticography (ERCP) or nasobiliary drainage (0.0% vs. 8.4%, P = 0.09). There were no long-term biliary complications for either group after three years of follow-up.CONCLUSIONS:Identification of biliary orifices with a bile leakage test and the suturing of cystobiliary communications significantly reduced postoperative biliary complications following hydatid liver surgery.

Intraoperative application of “white test” to reduce postoperative bile leak after major liver resection: results of a prospective cohort study in 137 patients

This study aimed to prove the clinical validation of the recently developed bile leakage test, "white test" (WT), in major liver resection. From June 2005 to June 2007, the study was carried out in a prospective consecutive fashion, including 74 patients without bile leakage test as the control group while 63 patients undergoing white test as the study group. The incidences of bile leakage within the 30th postoperative day in both groups were compared. Postoperative bile leakage was found in 22.9% patients in the control group and in 5.3% patients in the WT group, respectively (p < 0.01). In univariate analysis, not performing a white test, Klatskin tumor, biliary-enteric anastomosis, and longer operation time were associated with an increase of bile leakage. The multivariate analysis showed that not performing the WT was the only significant factor influencing the occurrence of postoperative bile leakage (p = 0.02). The white test is a feasible and sensitive bile leakage test with no obvious disadvantages. It could be a possible standardized method to prevent bile leakage in major liver resection.

The White Test

To describe a new intraoperative bile leakage test in patients undergoing a major liver resection aimed to combine the advantages of each of the other standard bile leakage tests (accurate visualization of leaks, reproducibility, and ease of use) without their disadvantages. At the end of the major hepatic resection, 10 to 30 mL of sterile fat emulsion, 5%, is injected via an olive-tip cannula through the cystic duct while manually occluding the distal common bile duct. As the biliary tree fills with fat emulsion solution, leakage of the white fluid is visualized on the raw surface of the liver resection margin. The detected leakages are closed by means of single stitches. Afterwards, the residual fat emulsion on the resection surface is washed off with saline and the White test is repeated to detect and/or exclude additional bile leakages. At the end, residual fat emulsion is washed out from the biliary tract by a low-pressure infusion of saline solution. Intraoperatively, additional potential bile leakages (not seen using a conventional saline bile leakage test) were identified in 74% of our patients. Postoperative bile leakages (within 30 days) occurred in only 5.1% of patients when the White test was used. No adverse effects related to this technique were observed. The White test has clear advantages in comparison with other bile leakage tests: it precisely detects bile leakages, regardless of size; it does not stain the resection surface, allowing it to be washed off and repeated ad infinitum; and it is safe, quick, and inexpensive.

Bile leakage after hepatic resection.

To identify the perioperative risk factors for postoperative bile leakage after hepatic resection, to evaluate the intraoperative bile leakage test as a preventive measure, and to propose a treatment strategy for postoperative bile leakage according to the outcome of these patients. Bile leakage remains a common cause of major complications after hepatic resection. Between January 1985 and June 1999, 781 hepatic resections without bilioenteric anastomosis were performed at the authors' institution. Perioperative risk factors related to postoperative bile leakage were identified using univariate and multivariate analysis. The characteristics of patients with intractable bile leakage and the effect of intraoperative bile leakage test were also examined. Management was evaluated in relation to the outcomes and the clinical characteristics of the patients with bile leakage. Bile leakage developed in 31 (4.0%) of 781 hepatic resections. This complication carried high risks for surgical death (two patients [6.5%] died). The stepwise logistic regression analysis identified high-risk surgical procedure, in which the cut surface exposed the major Glisson's sheath and included the hepatic hilum (i.e., anterior segmentectomy, central bisegmentectomy, or total caudate lobectomy), as the independent predictor of the development of postoperative bile leakage. None of the 102 cases in which an intraoperative bile leakage test was performed were subsequently complicated by postoperative bile leakage, and the preventive effect of the test was statistically significant. Patients with fisterographically demonstrable leakage from the hepatic hilum and with postoperative uncontrollable ascites had poor outcomes. Patients with bile leakage from the hepatic hilum and postoperative uncontrollable ascites tend to have a poor prognosis. Therefore, especially when a high-risk surgical procedure is performed in patients with liver cirrhosis, more careful surgical procedures and use of an intraoperative bile leakage test are recommended.

Invited critique

Hypothesis: An intraoperative bile leakage test will assist in decreasing postoperative bile leakage in patients undergoing hepatic resection. Design: Randomized controlled trial. Setting: University hospital. Patients: One hundred three consecutive patients who were scheduled for hepatic resection without biliary reconstruction. Associated cirrhosis was present in 49 patients (48%), and only 24 (23%) had normal livers. Patients were randomized to undergo (n=51) or to not undergo (n= 52) a bile leakage test, according to age, liver function, and hepatectomy method. The 2 groups were similar in baseline demographics. Intervention: A bile leakage test was carried out by injecting isotonic sodium chloride solution through the cystic duct, and interrupted suturing was taken for a bile leak on the transected liver surface. Main Outcome Measures: The incidence of postoperative bile leakage and the length of the postoperative hospital stay. Bile leakage was defined as continuous drainage, with a bilirubin level of 86 μmol/L or more (≥5 mg/dL), beyond 1 week. Results: Twenty-one patients (41%) in the test group showed a bile leak, and a median of 1 site (range, 1-6 sites) was closed during the test. Postoperative bile leakage was observed in 3 patients (6%) in the test group and in 2 (4%) in the control group (P=.99). The odds ratio of the event was 1.53 (95% confidence interval, 0.25-9.44). The median postoperative hospital stay lasted 17 (range, 13-47) and 18 (range, 12-41) days for the test and control groups, respectively (P=.98). Conclusion: This randomized trial suggested no advantage in using a bile leakage test during hepatic resection.

Occurrence of intraperitoneal septic complications after hepatic resections between 1985 and 1990.

In this study, the risk factors related to intraperitoneal septic complications occurring after hepatectomy (IPSCH) as well as the effect of various perioperative variables on the outcome of IPSCH between 1985 and 1990 were analyzed. Twenty-one of 211 patients (10.0%) developed IPSCH. The findings in the patients with IPSCH were compared with those in 190 patients without IPSCH. The significant variables associated with the development of IPSCH included a high incidence of accompanying chronic renal failure (14.3% vs 2.1%), a larger blood loss during surgery (2,130 vs 1,340 ml) as well as a greater amount of intraoperative blood replacement (1,130 vs 570 ml), and a greater weight of the resected liver (367 vs 233 g). IPSCH occurred in 10 of 12 patients who had postoperative bile leakage. Eighteen patients (85.7%) with IPSCH were discharged from the hospital after non-operative management; however, the hospital death rate (14.3% vs 1.1%) was significantly higher in patients with IPSCH. This review suggests that the incidence of IPSCH has not decreased recently. Thus, to prevent IPSCH, at least following bile leakage, it is necessary to perform a careful division of the liver parenchyma followed by a bile leakage test, and when this complication occurs unexpectedly in patients who have a good functional reserve of the remnant liver, IPSCH can be effectively drained percutaneously under ultrasound guidance.