Biliary Leakage Research Articles

Successful sequential management of traumatic choledochal leak and stenosis in children using ERCP: a case report and literature review

Traumatic Choledochal Leak and Stenosis in Children is a relatively rare bile leakage, and there is no report of endoscopic retrograde cholangiopancreatography [ERCP] bile duct stent treatment in 3 years old, which avoids procedure and biliary tract modifications after the failure of conservative treatment of bile leakage, and solves the previous need for procedure in a minimally invasive or even non-invasive way. At the same time, it can be concluded that identifying the signs of conservative treatment failure is important, and ERCP is superior to CT and MR in diagnosing traumatic biliary leak in young children. Traumatic bile leakage common bile duct inflammatory stenosis, brittle tissue, not suitable for expansion, the choice of 5 Fr to 10 Fr plastic stent sequential treatment is an effective regimen. At the same time, it is necessary to closely monitor the biliary patency after ERCP to understand the long-term postoperative efficacy. Comprehensive evaluation before ERCP and detailed post ERCP monitoring require the participation of pediatricians.

063. Characteristics and Predisposing Factors of Bile Duct Injury in Hasan Sadikin General Hospital

Background: Iatrogenic bile duct injuries (BDI) are associated with fatal complications and increased mortality. Bile duct injuries can be caused by imprecise bile duct cutting, dislodged surgical clips, tearing or obstruction by fibrosis as a result of thermal injury by electrocautery resulting in biliary leakage and/or stricture. The aim of this study is to identify characteristics and predisposing factors of bile duct injury in our center. Methods: This study is a cohort retrospective study, with 42 cases of iatrogenic BDI following cholecystectomy (after both open and laparoscopic approaches); both happened in or were referred to Hasan Sadikin Hospital from September 2023 to September 2024. Patients were classified according to age, gender, BMI, Strasberg – Bismuth classification, laboratory values, and imaging findings. Results: In this study, there were 43 subjects, with majority of subjects aged ?40 years old (58%). There was no difference in gender, with 22 males and 21 females. The mean BMI was 26.1 ± 5.1 kg/m2. Majority of the cases were type E2 Strasberg – Bismuth classification (76.7%). This study found age ?40 years old (p value = 0.00), abnormal preoperative liver function (p value = 0.01), and gallbladder wall thickening (p value = 0.01) as significant predisposing factors of BDI. Conclusion: Age ?40 years old, abnormal preoperative liver function, and gallbladder wall thickening are significant predisposing factors of BDI. Data of anatomical variations and surgeon’s expertise should be beneficial for improvement of future studies.

Capturing the incidence of patient agitation amongst conscious sedation ERCPs and the impact on therapeutic outcomes.

Completing advanced endoscopic procedures such as endoscopic retrograde cholangiopancreatography (ERCP) under conscious sedation is challenging. International recommendations favor enhanced sedation (e.g. propofol) for ERCP. Conscious sedation can result in sedation-related failure (SRF) and agitation for some patients, limiting therapeutic efficacy. The aim of this study is to establish the risk of SRF and the impact on therapeutic success under conscious sedation practice in a single tertiary referral center. A retrospective review of a prospectively maintained ERCP database, analyzing sedation, procedural success, and complications. Over 19 months, 807 conscious sedation ERCPs were recorded. Median midazolam dose was 5 mg (range 1-14 mg) and median fentanyl dose was 75 µg (0-200 µg). Sedation reversal was required in 0.1% of cases (1/807). Overall ductal cannulation rate was 92%. Severe agitation was recorded in 11% (86/807) of conscious sedation ERCP reports with SRF present in 3% (22/807). Patient agitation resulted in significantly lower cannulation (81% vs 92%, P = 0.002) and successful clearance rates (49% vs 85%, P = 0.002) versus non-agitated cases. Complication and pancreatitis rates were unaffected. Highest rates of SRF and agitation were identified in female patients, patients aged <50 years old, and post-operative biliary leak indications. Over 10% of conscious sedation ERCPs are compromised by sedation issues, resulting in procedure abandonment or significantly diminished therapeutic success. General anesthetic ERCP is beneficial in facilitating biliary access, removing the risk of agitation and providing stability to aid cannulation. Female patients, patients aged <50 years, and post-operative biliary leak ERCPs appear as the priority cases for enhanced sedation support.

Long term (15 year) complications & outcomes after liver transplantation for primary sclerosing cholangitis: Impact of donor and recipient factors.

With longer survival of patients with PSC undergoing liver transplantation (LT), the frequency and risk factors associated with vascular and biliary complications in the allograft and the impact on long-term outcomes are poorly understood. To assess frequency and risk factors for long term outcomes in patients post-LT for PSC. All LT recipients for advanced stage PSC for non-cholangiocarcinoma indication from 1984-2012, with follow-up through March 2022 (>10+year followup) were idenitfied. 1-, 5-, and 10-yr cumulative risks of complications were estimated using the Aalen-Johansen method, where death was considered a competing risk. Two hundred ninety-three patients (mean age, 47.3±12y), formed our study cohort. One hundred and thirty-four patients received LT before 1995 and the 159 were transplanted after 1995. Over a median (interquartile range) follow-up of 15.0 (10.3-22.1) years, LT was complicated by hepatic artery thrombosis (N=30), portal vein stenosis/thrombosis (N=48), biliary leak (N=47), biliary strictures (N=87), rPSC (N=107), and graft failure (N=70). The 1-, 5-, 10-, and 15-year cumulative incidence of rPSC was 1.0%, 8.0%, 23.5%, and 34.3% respectively. Type of donor and older donor age were associated with increased risk of biliary strictures. Donor age >60 years was associated with increased risk of rPSC. Long-term patient and graft-survival have not changed significantly for patients transplanted for PSC. Controlling transplant related factors such as donor age, prompt identification of vascular and biliary complications early and long-term rigorous followup is recommended to continue to improve on these outcomes.

Pancreaticogastrostomy: A Safe and Effective Reconstruction Method After Pancreaticoduodenectomy: A Short Observational Study

Background: Pancreaticoduodenal resection is usually performed in patients with a localised small carcinoma in the head of the pancreas, at the lower end of the common bile duct or at the ampulla and occasionally for chronic pancreatitis.The mortality following pancreaticoduodenal resection has fallen and is now below 5% 1-6 .However, leakage from the anastomosis between pancreas and the jejunum has been and remains, one of the most worrying complications of the operation. The data from papers published in the last 8 years show that the incidence of pancreatic leak is 14% and the mortality of this complication 24%3,4,6-16 .Pancreaticogastrostomy is a potentially safer alternative to pancreaticojejunostomy in the reconstruction following Whipple's operation. Aim: The aim of the study was to observe pancreaticogastrostomy is a potentially safer alternative to pancreaticojejunostomy after pancreaticoduodenectomy. Methods: This prospective observational study was conducted at the Department of Surgery in Shaheed Suhrawardy Medical College Hospital, for One year (August 2021 to July 2022). Patients with a localised small carcinoma in the head of the pancreas, at the lower end of the common bile duct or at the ampulla, and occasionally for chronic pancreatitis admitted in the department of surgery were approached for inclusion in the study. Total 41 patients were selected according to inclusion and exclusion criteria. Informed written consent was taken from each patient. All patients underwent pancreaticogastrostomy. Detail clinical and demographic history was taken along with thorough physical examination relevant investigations. All patients were evaluated preoperatively and post operatively at discharge, 1 month and 3 months. Outcome was assessed post operatively. Collected data were checked and analysed in SPSS 23. Results: Two patients died within 30 days of the operation (mortality 4.9%), one from perioperative haemorrhage and another from septicaemia due to a biliary infection, which may have resulted from preoperative transhepatic biliary drainage. Both operations were carried out for carcinoma of the head of the pancreas. One patient developed a biliary leak which closed in 6 days. A postoperative pancreatic leak occurred in one patient with carcinoma of the ampulla; the fistula closed after 5 mdays, and did not delay his discharge from hospital. This patient remains well 36 months after operation, although he has now developed mild diabetes.One other patient developed diabetes mellitus postoperatively. This woman had evidence of obstructive pancreatitis at operation. She died 6 months later of recurrent carcinoma of the head of the pancreas. One patient with chronic pancreatitis has uncontrolled steatorrhoea, with up to four bowel movements a day. Four other patients take regular pancreatic supplements together with H2 receptor antagonists in order to maintain normal defaecation. There has been no case of stomal ulceration. None of the patients were lost to follow-up. The median survival for patients operated on for carcinoma of the head of the pancreas was 13 months, and for patients with carcinoma of the bile duct, 14 months. Median survival of patients with ampullary carcinoma was 38 months. Conclusion: Seventy two percent of patients had good outcome after Pancreaticogastrostomy(PG). Significant relief in symptoms of pain were noted after PG. Further larger study is recommended to validate this findings. J Shaheed Suhrawardy Med Coll 2023; 15(1): 66-72

Safety and efficacy of using stapler device for wide cystic duct ligation in acute setting of laparoscopic cholecystectomy

This research explores the challenges posed by variations in cystic duct anatomy during laparoscopic cholecystectomy and the potential use of stapler devices to address such complexities. It aims to assess the safety and efficacy of stapler devices, particularly in cases involving short, and wide cystic duct. The study, conducted at King Abdulaziz Medical City in Riyadh, Saudi Arabia, between 2021 and 2023. The study design involved a retrospective cohort approach, and the sample size encompassed all cases meeting the inclusion criteria during the study period. Data was analyzed using SPSS program. The study involving 568 patients, with the predominant technique for ligation being clipping (89.3%). The primary indication for using the Endo GIA stapler was a wide cystic duct (6.2%). Analysis revealed a significant association between stapler device use and hypertension (p = 0.042), diabetes (p = 0.001), CKD (p = 0.011), and obstructive jaundice (p = 0.006). Multivariate regression demonstrated that older patients were 2.1 times more likely to use stapler devices (AOR = 2.125; p = 0.039), while those with obstructive jaundice had a 2.2 times higher likelihood (AOR = 2.168; p = 0.049). Throughout the years, metal clips have shown the best prognosis compared to any other method for securing the cystic duct during closure in laparoscopic cholecystectomy. However, to avoid incomplete sealing of wide, short, or inflamed ducts, other instruments have emerged as possible alternatives for such conditions. Use of Endo-GIA is a safe and effective method for patients with wide, short cystic duct. Selective usage of endo-GIA is considered cost effective and may add a positive impact in decreasing post operative biliary leak.

Early relaparotomy in recipients after living donor liver transplantation: causes, risk factors, and consequences.

Despite advancements in surgical methodologies and the extensive perioperative and postoperative care administered to recipients, the prevalence of complications requiring early relaparotomy following living donor liver transplantation (LDLT) remains persistent. This study sought to analyze the determinants influencing relaparotomy occurrences in the initial 30 days following LDLT. Additionally, it was aimed to evaluate the impact of early laparotomy on both graft and patient survival within this distinct patient cohort. The study encompassed recipients (n = 535) aged 18 years and older who underwent primary LDLT at our institution from January 2019 to December 2021. Exclusion criteria involved patients necessitating early retransplantation. Early relaparotomy was specified as surgical intervention within the initial 30 days following LDLT. The study enrolled a total of 535 patients, among whom 85 (15.9%) underwent early relaparotomy. The median age of the patients was 54 (range: 41-60) years, with a predominant male representation (66.2%). Univariate analysis comparing the laparotomy and nonrelaparotomy groups revealed statistically significant differences in the creatinine (p = 0.043) and sodium (p = 0.025) levels, graft side (p < 0.001), etiology (p = 0.005), and blood loss (p = 0.012).In the multivariate analysis, creatinine (p = 0.039; OR = 1.668; 95% CI = 1.027-2.709) and left lobe graft (p < 0.0001; OR = 3.611; 95% CI = 1.960-6.652) emerged as independent risk factors for relaparotomy. The primary causes of early relaparotomy following LDLT include postoperative bleeding, biliary leakage, and vascular complications. Preoperative elevation in creatinine and sodium levels, the presence of Budd-Chiari syndrome, utilization of a left lobe graft, and intraoperative blood loss are identified as risk factors associated with early relaparotomy after LDLT. Patients undergoing early relaparotomy exhibit inferior survival rates compared to those who do not.

Transhepatic Cholangiography and Biliary Drainage: Basic Concepts and Technique

AbstractPercutaneous transhepatic biliary procedures are essential for managing a variety of hepatobiliary conditions, particularly when endoscopic retrograde cholangiopancreatography is not feasible or has failed, or when patients are unstable. This review article provides a comprehensive overview of the indications, contraindications, and procedural steps for biliary puncture, focusing on techniques such as percutaneous transhepatic biliary drainage (PTBD) and percutaneous cholecystostomy. We also address strategies for accessing minimally dilated biliary systems and performing bedside PTBD. The article highlights the increasing demand for these interventions due to rising incidences of biliary diseases such as gallbladder cancer and cholangiocarcinoma, as well as complications arising from previous surgeries. Furthermore, we discuss common and life-threatening complications associated with these procedures, including biliary leaks, hemorrhage, and sepsis, and provide guidance on effective management strategies. Understanding these procedures and their potential complications is crucial for optimizing patient care and outcomes in complex biliary conditions.

Endoscopic or combined management of post-surgical biliary leaks: a two-center recent experience.

Post-surgical biliary leaks (PSBL) are one of the most prevalent and significant adverse events emerging after liver or biliary tract surgeries. Endoscopic retrograde cholangiopancreatography (ERCP) alone or combined with another approach (Rendez Vous) as treatment of PSBL obtains optimal outcomes due to the possibility of modifying the resistances in the biliary tree. A retrospective double-center study was conducted in two tertiary centers. Consecutive patients who underwent at least one attempt of PSBL correction by ERCP or Rendez Vous procedure between January 2018 and August 2023 were included. The primary outcome was overall endoscopic clinical success. In contrast, the secondary outcomes were hospital stay exceeding five days and endoscopic clinical success with the first endoscopic procedure at the tertiary center. Both univariate and multivariate analyses were used to assess outcomes. 65 patients were included. Patients with one or multiple) leaks had more possibility to achieve the endoscopic clinical success compared to those affected by the association of leaks and stricture (96% vs 67%, p value 0.005). Leaks occurring in the main biliary duct had less probability (67%) to achieve the overall endoscopic clinical success compared to those in the end-to-end anastomosis (90%), in the resection plane or biliary stump (96%) or first or secondary order biliary branches (100%, p value 0.038). A leak-bridging stent positioning had more probability of achieving the endoscopic clinical success than a not leak-bridging stent (91% vs 53%, p value 0.005). ERCP and Rendez Vous procedures are safe and effective for treating PSBL, regardless of the type of preceding surgery, even if technical or clinical success was not achieved on the first attempt. A stent should be placed, if feasible, leak-bridging to enhance treatment efficacy.

Case Report: When Arteries Betray: Massive Post-transplantation Hemorrhage

Hepatic artery pseudoaneurysm is a rare complication that may occur in the setting of liver transplantation and other traumatic instrumentation of the hepatobiliary system. This condition poses a significant morbidity and mortality risk and must be diagnosed and intervened upon emergently. Herein we present a case of hepatic artery pseudoaneurysm complicated by hemorrhagic shock in the setting of a post-liver transplant biliary leak. In this case, the patient was ultimately diagnosed via hepatic angiogram, treated with hepatic artery embolization, and required subsequent retransplantation. The objective of this case was to demonstrate the importance of maintaining a high clinical suspicion for hepatic artery pseudoaneurysm in the post-transplant setting, emphasize the use of computed tomography angiography as a primary diagnostic tool, and involving interventional radiology early in the treatment course.

Indocyanine Green and Hepatobiliary Surgery: An Overview of the Current Literature.

Indocyanine green (ICG) is an inert polypeptide that almost totally binds to high molecular weight plasma proteins; it is cleared by the hepatocytes and directly excreted into the bile with a half-life of about 3-5 minutes. Specific systems are required to see fluorescent images. The use of this dye has been reported in different surgical specialties, and the applications in hepatobiliary surgery are widening. Being firstly used to evaluate the preoperative liver function, intra- and postoperative dynamic checking of hepatic activity has been reported and integrated within perioperative protocols allowing a tailored treatment allocation. Intravenous injection (IV) or injection into the gallbladder can ease difficult cholecystectomy. Biliary leakage detection could be enhanced by IV ICG injection. Although with some contrasting results, the use of ICG for both delineating the limits of the resection and tumor-enhanced visualization was demonstrated to improve short- and long-term outcomes. Although the lack of strong evidence still precludes the introduction of this tool in clinical practice, it harbors great potential in liver surgery.

Application of indocyanine green during laparoscopic cholecystectomy in elderly and senile patients

Aim. To evaluate an effect of fluorescence cholangiography for intraoperative identification of extrahepatic bile ducts on the treatment outcomes of patients with cholelithiasis.Materials and methods. The study included 71 cholelithiasis patients who underwent laparoscopic cholecystectomy with fluorescence cholangiography and 69 cholelithiasis patients who underwent standard laparoscopic cholecystectomy. The study analyzed intraoperative damage of extrahepatic bile ducts and arteries, duration of surgery, conversion rate, need for colleague assistance, incidence of postoperative complications, hospital length of stay, and outcomes.Results. Fluorescence of the vesicular duct was achieved in 100% of patients, of the common bile duct – in 91%, and of the common hepatic duct – in 64%. A correlation between the number/type of complications and the application of ICG-diagnostics was found statistically significant (p &lt;0.001, p = 0.012), thereby indicating the advantages of the method. The colleague-surgeon assistance was required in the ICG group 35 times less than in the standard surgery group (OR = 0.029; 95% CI = 0.003–0.319). A 34-minute reduction in surgery duration (linear regression) can be expected when performing ICG-guided surgery.Conclusion. The application of fluorescence cholangiography reduces the probability of postoperative complications, in particular, biliary leakage with the necessity of reoperation. Due to the method, a surgeon appears able to complete the operation independently without colleague assistance. Treatment outcomes, incidence of bile duct injuries, and conversion rate are yet to be investigated.

Central Liver Segments Resections vs Extended Hepatectomies in Children: Single-center Experience

BackgroundCentral liver segments resection (CLSR) still is not widely used in pediatric surgery due to its technical difficulty, whereas this procedure is widely spread as a parenchyma sparing approach of centrally located liver tumors in adults. The aim of this study is to analyze the outcomes of CLSR in comparison with extended hepatectomy (EH) in children with different liver tumors. MethodsA single-center retrospective analysis of patients who received CLSR (n = 14) and EH (n = 44) from June 2017 to December 2023 was applied. Patient's characteristics, preoperative, intra- and postoperative data were compared between 2 groups. ResultsPreoperative CT-volumetry showed that future liver remnant volume was higher in CLSR group compared to EH (FLR-V; (54 ± 29 (40–91) % vs 40 ± 12 (17–73) %, p = 0.016). The intraoperative blood loss (200 [90–1150] (20–3000) ml vs 100 [30–275] (10–9000) ml, p = 0.088) and transfusion volume (310 [85–590] (0–1860) ml vs 150 [0–310] (0–4770) ml, p = 0.484) were similar in both groups, while operation time was longer in CLSR group (420 [320–595] (145–785) min vs 280 [203–390] (125–710) min), p = 0.011). There was no difference in biliary leakage (3 (21.4 %) vs 12 (27.3 %); p = 0.479), other complications (4 (28.6 %) vs 5 (11.4 %), p = 0.198) and complications ≥ IIIb by Clavien-Dindo (2 (14.3 %) vs 8 (18.2 %), p = 0.385) postoperatively. ConclusionCLSRs allow to preserve more healthy liver parenchyma compared to EH with similar intraoperative and postoperative outcomes. «Extended mesohepatectomy» allows to achieve R0 resection when central liver tumor extends on the left lateral and/or right posterior section. Type of StudyRetrospective Comparative Study (Level of Evidence III).

The use of indocyanine green fluorescence imaging in preventing postoperative bile leakage of the hepaticojejunostomy in robot-assisted pancreatic surgery

BackgroundPostoperative bile leakage (POBL) due to insufficiency of the hepaticojejunostomy (HJ) after pancreatico-duodenectomy (PD) is associated with high morbidity and mortality. The aim of this cohort study was to determine the clinical relevance of ICG in detecting and preventing POBL of the HJ in robotic minimal invasive pancreatic surgery (R-MIPS). MethodsAll consecutive robot- and ICG-assisted HJ-anastomoses between 2019 and 2022 were included. Biliary leakage was objectified with near infrared technology. Only clinically relevant POBL were considered in this study. ResultsSixty patients who underwent a PD between 2019 and 2022 were included. In ten patients, fluorescence imaging revealed an intra-operative hepaticojejunostomy insufficiency (HJI). Five of these patients developed POBL despite revision but preventing POBL in five patients. Detection of HJI with ICG predicted POBL with a sensitivity and specificity of 41.6% and 89.6% respectively. There was a significant higher chance of developing a POBL if the hepatic duct diameter was less than 5 mm (relative risk = 4.68 (p = 0.0345)), or if an intra-operative HJI was detected (relative risk = 3.57 (p = 0.009)). ConclusionICG is a simple and useful tool for detecting intra-operative bile leakage. This study shows that bile illumination with ICG in R-MIPS could prevent postoperative bile leakage.

Risk factors for biliary strictures and leaks after living-donor liver transplantation: a systematic review and meta-analysis

BackgroundLiver transplantation is the only curative treatment of end-stage liver disease. Unfortunately, a significant number of patients on the organ waitlist die waiting for an organ. Living-donor liver transplantation (LDLT) is an approach that has been used to expand organ availability. Although LDLT has excellent outcomes, biliary complications remain a significant drawback. This meta-analysis aimed to precisely assess the predictors of biliary stricture and leak after LDLT. MethodsPubMed, Embase, and Web of Science databases were searched from inception to January 2024. Only studies that used a multivariate model to assess risk factors for post-LDLT biliary stricture or leak in adult participants were included. Studies reporting unadjusted risk factors were excluded. Pooled adjusted odds ratios (ORs) and pooled hazard ratios (HRs) with 95% CIs for risk factors reported in ≥2 studies were obtained within a random-effects model. ResultsOverall, 22 studies with 9442 patients who underwent LDLT were included. The post-LDLT biliary stricture rate was 22%, whereas the post-LDLT biliary leak rate was 14%. In addition, 13 unique risk factors were analyzed. Postoperative bile leak (OR, 4.10 [95% CI, 2.88–5.83]; HR, 3.88 [95% CI, 2.15–6.99]) was the most significant predictor of biliary stricture after LDLT. Other significant predictors of biliary stricture after LDLT were right lobe graft (OR, 2.56; 95% CI, 1.23–5.32), multiple ducts for anastomosis (OR, 1.62; 95% CI, 1.08–2.43), ductoplasty (OR, 2.07; 95% CI, 1.36–3.13), ABO incompatibility (OR, 1.45; 95% CI, 1.16–1.81), and acute cellular rejection (OR, 4.10; 95% CI, 2.88–5.83). Donor bile duct size (HR, 0.82; 95% CI, 0.74–0.91; P = .001, I2 = 0%) was found to be significantly associated with reduced risk of post-LDLT biliary stricture. Donor age, recipient age, recipient male sex, and duct-to-duct anastomosis were not associated with an increased risk of post-LDLT biliary strictures. Multiple ducts for anastomosis (OR, 1.86; 95% CI, 1.43–2.43) was a significant predictor of post-LDLT biliary leak. Recipient age, warm ischemia time, and duct-to-duct anastomosis were not associated with an increased risk of post-LDLT biliary leak. ConclusionIn this meta-analysis, 7 unique risk factors were shown to be predictive of post-LDLT biliary stricture, one of which was associated with both post-LDLT biliary stricture and leak. Donor bile duct size was found to be protective against post-LDLT biliary strictures. Identifying reliable predictors is crucial for recognizing high-risk patients. This approach can facilitate the implementation of preventive measures, surveillance protocols, and targeted interventions to reduce the incidence of biliary strictures after LDLT.

Evaluation of Safety and Feasibility of Using LigaSure During Clipless Single-Incision Laparoscopic Cholecystectomy: A Prospective Clinical Study.

Background: Single-incision laparoscopic cholecystectomy (SILC) is a minimally invasive procedure designed to minimize the number and size of the incisions needed for cholecystectomy. Titanium clips are traditionally used to close the cystic duct and artery. Although it is considered safe, dislodgement can result in bleeding and biliary leakage. Using LigaSure for duct sealing is still controversial. The aim of this study was to evaluate the safety and feasibility of using LigaSure to close the cystic duct during SILC. Methods: A prospective study over two years was conducted at the General Surgery Department, Mansoura University Hospital, on 102 patients, 51 in each group. They underwent SILC using LigaSure (Group 1) or titanium clips (Group 2) to control the cystic duct and artery. Results: The data analyzed included demographic data, operative time, intra- and postoperative complications, postoperative pain, and hospital stay. The operative time was significantly shorter in LigaSure group (68.5 ± 9.8 versus 72.9 ± 10.6 minutes in the clips group, P .03). There was no significant difference between the two groups regarding postoperative bile leak or bleeding. However, two cases in Group 1 and four cases in Group 2 were converted to multiple port laparoscopic cholecystectomy; this was statistically nonsignificant. Postoperative pain and hospital stay showed no significant difference between the two groups. Two patients in each group developed port-site incisional hernia. Conclusions: Clipless SILC using LigaSure is a feasible and safe procedure with acceptable morbidity with shorter operative time than SILC using clips. Nevertheless, the risk of port-site incisional hernia should be explained to the patients.

Late cholangitis after pancreatoduodenectomy: A common complication with or without anatomical biliary obstruction

BackgroundPostoperative cholangitis is a common complication after pancreatoduodenectomy that can occur with or without anatomical biliary obstruction. This study aimed to investigate the incidence, diagnosis, treatment, and risk factors of cholangitis after pancreatoduodenectomy. MethodsWe performed a retrospective cohort study of consecutive patients who underwent pancreatoduodenectomy in 2 Dutch tertiary pancreatic centers (2010–2019). Primary outcome was postoperative cholangitis, defined as systemic inflammation with abnormal liver tests without another focus of infection, at least 1 month after resection. Diagnostic and therapeutic strategies were evaluated. Two types of postoperative cholangitis were distinguished; obstructive cholangitis (benign stenosis of the hepaticojejunostomy) and nonobstructive cholangitis. Potential risk factors were identified using logistic regression analysis. ResultsPostoperative cholangitis occurred in 93 of 900 patients (10.3%). Median time to first episode of cholangitis was 8 months (interquartile range 4–16) after pancreatoduodenectomy. Multiple episodes of cholangitis occurred in 44 patients (47.3%) and readmission was necessary in 83 patients (89.2%). No cholangitis-related mortality was observed. Obstructive cholangitis was seen in 37 patients (39.8%) and nonobstructive cholangitis in 56 patients (60.2%). Surgery was performed for cholangitis in 7 patients (7.5%) and consisted of revision of the hepaticojejunostomy or elongation of the biliary limb. Postoperative biliary leakage (odds ratio 2.56; 95% confidence interval 1.42–4.62; P = .0018) was independently associated with postoperative cholangitis. ConclusionPostoperative cholangitis unrelated to cancer recurrence was seen in 10% of patients after pancreatoduodenectomy. Nonobstructive cholangitis was more common than obstructive cholangitis. Postoperative biliary leakage was an independent risk factor.

Impact of post-hepatectomy biliary leaks on long-term survival in different liver tumors: A single institute experience.

A postoperative biliary leak is one of the most morbid complications occurring after a liver resection, the long-term impact of which remains unknown. Retrospective analysis of consecutive liver resections performed from 1 January 2011 to 31 December 2021. Primary endpoint of disease-free survival (DFS) was compared between patients with and without a bile leak, stratifying for tumor type. Survival curves were plotted using Kaplan-Meier estimates, and differences between them were analyzed using the log-rank test. In toto, 862 patients were analyzed, and included 306 (35.5%) hepatocellular carcinomas, 212 (24.6%) metastatic colorectal cancers, and 111 (12.9%) cholangiocarcinomas (69 intrahepatic cholangiocarcinomas, 42 hilar cholangiocarcinomas). Occurrence of a bile leak was associated with significantly poorer DFS only in patients with cholangiocarcinoma (median DFS 9.9 months vs. 24.9 months, p = 0.013), and further analysis was restricted to this cohort. A Cox regression performed for factors associated with DFS detriment in patients with cholangiocarcinoma showed that apart from node positivity (hazard ratio [HR]: 2.482, p = 0.033) and margin positivity (HR: 2.65, p = 0.021), development of a bile leak was independently associated with worsening DFS on both univariate and multiple regression analyses (HR: 1.896, p = 0.033). Post-hepatectomy biliary leaks are associated with significantly poorer DFS only in patients with cholangiocarcinoma, but not in patients with hepatocellular carcinoma or metastatic colorectal cancer. Methods to mitigate this survival detriment need to be explored.

Endoscopic Management of Pancreaticobiliary Injuries: A Level 1 US Trauma Center Experience.

Background: Traumatic pancreaticobiliary injuries are challenging to diagnose and manage. Endoscopic retrograde cholangiopancreatography (ERCP) has potential diagnostic and therapeutic utility in cases of traumatic pancreaticobiliary injuries. Methods: In this single-center retrospective study, we assessed 25 cases of abdominal trauma in which the patients underwent ERCP for management of suspected pancreaticobiliary injuries. We analyzed basic patient demographics, mechanism of trauma, method of diagnosis, ERCP results, surgical treatments, and outcomes. Results: Of the 25 assessed patients, 12 (48%) had pancreatic injuries, 12 (48%) had biliary injuries, and 1 (4%) patient had both. The median age was 28 years [IQR 25-35], and 84% of patients were males. Fifty-six percent of injuries were from blunt trauma, while 44% were from penetrating trauma. In cases of ERCP-confirmed biliary leaks (n=11), 100% of leaks were resolved in the 8 patients who underwent repeat ERCP after initial ERCP with stenting. In cases of ERCP-confirmed pancreatic duct leaks (n=10), 57% of duct leaks were resolved in the 7 patients who underwent repeat ERCP after initial ERCP with stenting. One patient in the biliary trauma cohort developed post-ERCP pancreatitis and sepsis. Conclusion: ERCP was a useful diagnostic and therapeutic intervention in this population of patients with pancreaticobiliary trauma.

Assessment of Early Laparoscopic Cholecystectomy in Management of Acute Calcular Cholecystitis

Abstract Background Acute cholecystitis is one of the most significant diseases in the Western world and has a high socioeconomic impact. Mainly, patients with gallstones and older adults are affected. The main complication of acute cholecystitis is recurrent biliary colic and cholestasis. The latter may lead to ascending cholangitis, and while this can be managed with antibiotics, other complications cannot be cured conservatively such as gangrenous changes, gall bladder perforation and biliary leakage, and acute necrotic gallstone pancreatitis. Liver abscesses and underlying incidental carcinoma have also been reported in some cases. Aim of the Work The purpose of this study is to focus on success rate of early laparoscopic cholecystectomy as a management of acute calcular cholecystitis along with its operative and post- operative outcomes. Patients and Methods This is a prospective cohort study conducted on forty (40) patients presenting to Ain-Shams University hospitals and authorized hospitals presented with acute calcular cholecystitis starting from January 2021 and December 2021. Results Our study demonstrates that in terms of morbidity and mortality, early laparoscopic cholecystectomy is safe, feasible and cost-effective for cases of acute cholecystitis. The outcome of the patients in our study provides further evidence that early laparoscopic cholecystectomy can be performed within the first 72 hours of symptoms with no significant increase in length of operation. Moreover, there was no significant increase in the rate of major intra operative or post operative complications such as bleeding, bile duct injury, bowel injury, wound infection and conversion to open cholecystectomy. The major advantage of early cholecystectomy was that early laparoscopic cholecystectomy allows significantly shorter total hospital stay and reduction in days away from work. Moreover, it avoids repeated admissions for recurrent symptoms. Conclusion Early laparoscopic cholecystectomy is safe, feasible and cost-effective for cases of acute cholecystitis and its major advantage is that it allows significantly shorter total hospital stay and reduction in days away from work and avoids repeated admissions for recurrent symptoms.