Biliary Leakage Research Articles

Robotic Liver Resection: Report of Institutional First 100 Cases

Backgrounds: Liver surgery has developed progressively during the last 10 years, especially in minimally invasive approaches. Robotic surgery seemed to overcome laparoscopic limitations with 3D visualization, the increased degrees of freedom given with Endowrist instruments, tremor filtering, better dexterity, and improved ergonomics for the surgeon. Methods: This work was a retrospective analysis of our first 100 robotic hepatectomies from March 2020 to July 2022. Patient demographics characteristics and intra- and postoperative outcomes were analyzed. Results: A total of 59 males and 41 females, with a median age of 68 years, underwent a robotic liver resection. The indications for robotic liver resections were malignant lesions in 86% of patients. Anatomical resection (AR) was undertaken in 27% of cases and non-anatomical resection (NAR) in 63% of cases. None of the patients were converted to the ‘open’ approach. Postoperative complications were as follows: 1% of biliary leakage, 5% of ascites, 6% of pulmonary infections, and 3% of other sites’ infections. CONCLUSIONS Our results showed the satisfactory experience of a tertiary HPB center with its first 100 robotic liver resections. The opportunity to make the robotic approach routinary provided global growth of a surgical team, improving the quality of patient outcomes.

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

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

Uncommon Complication of a Biliary Leak After Adjustable Gastric Band Removal: A Case Report

Uncommon Complication of a Biliary Leak After Adjustable Gastric Band Removal: A Case Report

Hepatobiliary-specific magnetic resonance contrast agents: role in biliary trauma.

Non-iatrogenic traumatic bile duct injuries (NI-TBIs) are a rare complication after abdominal trauma, with an estimated prevalence of 2.8-7.4% in patients underwent blunt liver injuries. They may be overlooked in patients with extensive multi-organ trauma, particularly hepatic, splenic and duodenal injuries, which have a prevalence of 91%, 54% and 54%, respectively. Whole body contrast-enhanced computed tomography (CE-CT) represents the examination of choice in polytraumatized hemodynamically stable patients, as it allows a comprehensive evaluation of vascular, parenchymal, bone and soft tissues injuries, but the diagnosis of any biliary leaks is limited to the evaluation of nonspecific imaging findings and on findings evolution in the follow-up, such as the progressive growth of fluid collections. Furthermore, biliary complications, such as the occurrence of biloma or biliary peritonitis, may become manifest several days after the initial trauma, often with unspecific progressive signs and symptoms. Although CT and ultrasonography can suggest bile leaks based on several nonspecific imaging findings (e.g., fluid collections), magnetic resonance imaging (MRI) using hepatobiliary contrast agents helps to identify the site and entity of post-traumatic biliary disruption. Indeed, MRI allows to obtain cholangiographic sequences that may show post-traumatic active bile leakage and cysto-biliary communications by direct visualisation of contrast material extravasation into fluid collections, increasing the preoperative accuracy of NI-TBIs. Few data are available about MRI use in the follow-up of trauma with NI-TBI management. So, in the present mini review, its role is reviewed and our preliminary experience in this field is reported.

S2114 A Case of Postoperative Biliary Leak in a Patient With Duplicated Cystic Ducts

S2114 A Case of Postoperative Biliary Leak in a Patient With Duplicated Cystic Ducts

Percutaneous transhepatic biliary drainage (PTBD) in patients with biliary leakage: Technical and clinical outcomes.

The purpose of this study is to evaluate the technical and clinical outcome of percutaneous transhepatic biliary drainage (PTBD) in patients with biliary leakage. All patients who underwent ultrasound-assisted PTBD between January 2017 and December 2021 due to biliary leakage with nondilated biliary systems were retrospectively evaluated for periprocedural characteristics, medical indications, technical success (successful placement of drainage catheter), clinical success (resolved leak without additional procedures), fluoroscopy time, procedure duration, and clinical outcomes. 74 patients with a mean age of 64.1 ± 15.1 years were identified. Surgery was the most common etiology of biliary leak with 93.2% of the cases. PTBD had a 91.8% (68/74) technical success rate and an 80.8% clinical success rate. The mean procedure and fluoroscopy duration were 43.5 and 18.6 minutes. Age > 65 years (P = .027) and left-sided drainage (P = .034) were significant risk factors of clinical failure. Procedure-related major complications were 2 bleedings from the liver and 1 bleeding from an intercostal artery (major complication rate 4%). PTBD is a feasible, safe, and effective treatment option in patients with biliary leakage with low complication rates.

Ectopic Opening of Common Bile Duct to Duodenal Bulb: A Single Tertiary Center Experience.

The ectopic opening of the common bile duct(CBD) into the duodenal bulb is a rare biliary anomaly. The study aimed to reveal the experience with clinical and endoscopic outcomes in these patients. This study was conducted on 57 consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for ectopic opening of the CBD into the duodenal bulb at our institution between 2010 and 2020. The median age was 59 years (49 males). A total of 146 ERCP procedures were performed (once in 26 patients and 2 or more times in 31 patients). Ten patients had a history of unsuccessful ERCP in an external center. The median follow-up time was 14.6 months. All patients had a slit-like opening of the CBD into the duodenal bulb, apical stenosis, and hook-shaped distal CBD. ERCP findings were CBD stone or dilatation in 55 patients and post-cholecystectomy biliary leakage in 2 patients. Balloon dilatation was performed for apical stenosis in 7 patients and distal CBD stenosis in 26 patients. During the first ERCP session, biliary stent/nasobiliary drainage was placed in 37 patients, and CBD stones were extracted in 19 patients without stenting. Biliodigestive anastomosis was applied to 13 patients, 5 of whom had recurrent cholangitis, 7 required recurrent ERCP, and one was due to the technical difficulty of ERCP. Ectopic biliary opening should be remembered if the papilla cannot be seen in its usual place in a patient with apical stenosis. ERCP should be performed in experienced hands, and surgery should be considered in the need for recurrent ERCP.

T‑tube versus internal drainage tube in laparoscopic common bile duct exploration.

The 203 patients who underwent laparoscopic common bile duct exploration for choledocholithiasis were retrospectively analyzed. The patients were divided into internal drainage tube group (n=87) and T-tube group (n=116). Total bilirubin, direct bilirubin, alanine aminotransferase (AST), aspartate aminotransferase (ALT), the diameter of common bile duct, number of stones, operation time, intraoperative bleeding, postoperative hospital stay and postoperative complications were compared between the two groups. Possible influencing factors were selected as independent variables, and the operation mode was selected as the dependent variable for multifactor unconditional logistic regression analysis. There were no significant differences in the sex, age, total bilirubin, direct bilirubin, AST, ALT, operation time, intraoperative blood loss, postoperative hospital stay and postoperative biliary leaks between the two groups (P>0.05). The diameter of the common bile duct was smaller and the incidence of multiple stones in the common bile duct was lower in the internal drainage tube group compared with that in the T-tube group (P<0.05). The results of multifactor unconditional logistic regression analysis demonstrated that the diameter of the common bile duct and the number of stones in the common bile duct were associated with the operation mode as influencing factors. In conclusion, Patients with multiple stones in the common bile duct or with a wide diameter of the common bile duct are more likely to have T-tube placed rather than an internal drainage tube.

Does inclusion of bioactive n-3 PUFAs in parenteral nutrition benefit postoperative patients undergoing liver surgery? A systematic review and meta-analysis of randomised control trials

ObjectivesThis meta-analysis aims to evaluate the effect of n-3 polyunsaturated fatty acids (PUFAs) as a part of parenteral nutrition in patients undergoing liver surgery.DesignSystematic review and meta-analysis.Data sourcesPubMed, the Cochrane...

Crossing borders to change lives: Surgical mission amidst the COVID-19 pandemic

IntroductionDuring the COVID pandemic, elective global surgical missions were temporarily halted for the safety of patients and travelling healthcare providers. We discuss our experience during our first surgical mission amidst the pandemic. We report a safe and successful treatment of the patients, detailing our precautionary steps and outcomes. MethodsRetrospective manual chart review and data collection of patients’ charts was conducted after IRB approval. We entail our experience and safety steps followed during screening, operating and postoperative care to minimize exposure and improve outcomes during a surgical mission in an outpatient setting during the pandemic. The surgical mission was from February 8 to February 12, 2022. ResultsA total of 60 patients who were screened. 33 patients underwent surgical intervention. One patient required postoperative hospitalization for a biliary duct leak. No patient or healthcare provider tested positive for COVID at the end of the mission. The average age of patients was 46.9 years. The average operative time was 116 min, and all patients had local nerve blocks. It included 45 health work providers. ConclusionsIt is safe to perform outpatient international surgery during the pandemic while following pre-selected precautions.

Post-cholecystectomy biliary leakage mimicking a neoplastic lesion: contribution of cholangioscopy in diagnosis and endoscopic treatment.

Post-cholecystectomy biliary leakage mimicking a neoplastic lesion: contribution of cholangioscopy in diagnosis and endoscopic treatment.

Use of gelatin sponge to seal the biliary tract after percutaneous transhepatic biliary drainage in patients with liver transplants.

Percutaneous transhepatic biliary drainage (PTBD) is commonly used in the treatment of malign and benign biliary pathologies. Certain complications after PTBD may occur, such as biliary fistula, biliary leakage, bilioma, and hematoma. The purpose of this study was to evaluate the safety and effectiveness of using a sterile gelatin sponge to seal the biliary tract after PTBD in patients with liver transplants to prevent complications. A total of 131 biliary drainages were introduced in 97 patients, and a sterile gelatin sponge was used to seal the biliary tract after removal of the biliary drainage catheter. The patients were immediately examined for complications using ultrasound and then followed up clinically unless imaging was required. Five fluid collections within the liver with a diameter <2 cm, consistent with hematoma or bilioma, were resolved spontaneously. No hematoma or bilioma required treatment, and no biliary leakage or fistula was detected. No compli¬cations related to the use of the sponge were observed. The use of a sterile gelatin sponge is a safe and effec-tive method for sealing the biliary tract to prevent complications after PTBD in patients with liver transplants.

Post-transplant biliary complications using liver grafts from deceased donors older than 70 years: Retrospective case-control study.

The shortage of liver grafts and subsequent waitlist mortality led us to expand the donor pool using liver grafts from older donors. To determine the incidence, outcomes, and risk factors for biliary complications (BC) in liver transplantation (LT) using liver grafts from donors aged > 70 years. Between January 1994 and December 31, 2019, 297 LTs were performed using donors older than 70 years. After excluding 47 LT for several reasons, we divided 250 LTs into two groups, namely post-LT BC (n = 21) and without BC (n = 229). This retrospective case-control study compared both groups. Choledocho-choledochostomy without T-tube was the most frequent technique (76.2% in the BC group vs 92.6% in the non-BC group). Twenty-one patients (8.4%) developed BC (13 anastomotic strictures, 7 biliary leakages, and 1 non-anastomotic biliary stricture). Nine patients underwent percutaneous balloon dilation and nine required a Roux-en-Y hepaticojejunostomy because of dilation failure. The incidence of post-LT complications (graft dysfunction, rejection, renal failure, and non-BC reoperations) was similar in both groups. There were no significant differences in the patient and graft survival between the groups. Moreover, only three deaths were attributed to BC. While female donors were protective factors for BC, donor cardiac arrest was a risk factor. The incidence of BC was relatively low on using liver grafts > 70 years. It could be managed in most cases by percutaneous dilation or Roux-en-Y hepaticojejunostomy, without significant differences in the patient or graft survival between the groups.

A Modified Surgical Technique in Biliary Reconstruction in Living Donor Liver Transplantation and Its Impact on Postoperative Incidence of Biliary Leakage and Stricture

Abstract Background Biliary complications continue to be a challenging territory in living donor liver transplantation that could lead eventually to graft loss and increased mortality. Despite the continuous evolution of biliary reconstruction techniques, there is no single full proof method that could possibly ensure the best biliary reconstruction. Aim of work In this study we compare the results of our combined modified technique of biliary reconstruction to the results of the conventional techniques in terms of improving biliary complications particularly biliary leaks and strictures. Methods This study was conducted on two equal groups of patients (recipients), 52 each, one of them received the conventional technique and the other received the modified technique. Results Our results have shown that the modified technique dropped the biliary complications from 36.5 to 9.6%, bile leaks dropped from 9.6% to 3.8%, and strictures dropped from 30.8% to 7.7%. Conclusion HPGS approach in the donor surgery together with en bloc hilar dissection and the eversion technique in the recipient surgery improve postoperative biliary complications.

Co-Relation between MELD Scoring System prior Living Donor Liver Transplantation and Occurrence of Post-Transplant Biliary Complications

Background Liver transplantation is considered the treatment of choice for patients with end stage liver disease who have failed standard medical and surgical therapy. The development of liver transplantation has revolutionized the field of hepatology and greatly improved the outlook of patients suffering from various liver diseases. The Model for EndStage Liver Disease, or MELD, is a scoring system for assessing the severity of chronic liver disease. It was initially developed to predict mortality within three months of surgery in patients who had undergone a transjugular intrahepatic portosystemic shunt (TIPS) procedure and was subsequently found to be useful in determining prognosis and prioritizing for receipt of a liver transplant. This score is now used by the United Network for Organ Sharing (UNOS) and Eurotransplant for prioritizing allocation of liver transplants instead of the older Child-Pugh score. Biliary tract complications are abundantly occurring post-operative, and they may include a variety of scenarios, as biliary leakage, ischemic bile duct injuries, and biliary stenosis. Aim of the Work Aim of the work is to study the relation between the Model of End Stage Liver Disease (MELD) scoring system and the occurrence of post liver transplantation biliary complications. Patients and Methods A combined retrospective and prospective cohort study was carried out. We retrospectively analyzed the available database of all patients that underwent LDLT, at Ain Shams Center of Organ Transplantation (ASCOT), during the period from January 2013 till May 2019, and suffered from post-operative biliary complications during the first 3 months Post-operative and correlated it with their MELD score before the operation. To do so, we studied 50 patients that are aged more than or equal 18 years old, any gender, that underwent living donor liver transplantation. We excluded patients with cholestatic liver disease and patients that underwent preoperative biliary intervention. All patients were subjected to complete history taking and thorough clinical examination, full laboratory workup, full radiological workup, post-operative cholangiography and Endoscopic retrograde colangio-pancreatography if needed.

Safety of Concomitant Laparoscopic Cholecystectomy and Laparoscopic Sleeve Gastrectomy in Morbidly Obese Patients: A Meta-Analysis

Abstract Background Laparoscopic sleeve gastrectomy is one of the most common bariatric procedure performed. The prevalence of cholelithiasis in morbidly obese individuals is 19–30 % and Gall stones are more symptomatic in obese patients than in non-obese patients. This study evaluates the safety of performing laparoscopic sleeve gastrectomy and laparoscopic cholecystectomy in the same session. Objective To evaluate the safety profile of performing laparoscopic cholecystectomy and sleeve gastrectomyin the same session in terms of : The incidence of biliary leakage. The incidence of gastric leakage. The incidence of intra operative bleeding from the sleeve gastrectomy and the cholecystectomy. The incidence of post-operative bleeding. The incidence of post-operative surgical site infection. Operation time. Length of hospital stay. Method Selected papers for the present meta-analysis included those that provided data from January 2010 to December 2020 on factors related to the patients who undergone laparoscopic sleeve gastrectomy with and without laparoscopic cholecystectomy. When institutions have published duplicate trials, only the most updated reports were included for qualitative appraisal. All publications were limited to human subjects and English language. Abstracts, case reports, conference presentations, editorials and expert opinions were excluded. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2021. Data Extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information and defined assessment measures. Conclusion Overall concomitant laparoscopic sleeve gastrectomy and laparoscopic cholecystectomy appears to be a safe procedure. The increase in surgical site infection and pneumonia may warrant prophylaxis against such infections with antibiotics. Another study is needed to determine the need and efficacy of such prophylaxis

Efficacy and associated factors of endoscopic transpapillary drainage for postoperative biliary leakage.

Adequate biliary decompression is important in treating bile leaks, and endoscopic transpapillary drainage is widely used for this purpose. As an indicator to evaluate the usefulness of endoscopic drainage for postoperative biliary leakage, we focused on external drain removability, which affects quality of life, after endoscopic treatment. Our aim was to clarify the success rate of external tube removal after endoscopic drainage for postoperative biliary leakage and to examine associated factors. This was a multicenter retrospective study; 99 patients with biliary leakage at 13 institutions were enrolled between April 2014 and March 2019. Among these patients, 66 who were initially treated with endoscopic interventions for biliary leakage after cholecystectomy (n = 17) or hepatectomy (n = 49) were reviewed. In post-cholecystectomy biliary leakage, the external-drain-free rate at first endoscopic intervention was 100%, and the drains, including transpapillary stents, were successfully removed in almost all cases (16/17). In contrast, in post-hepatectomy biliary leakage, the external-drain-free rate was 44.9% (22/49), with all 22 of those patients eventually becoming entirely drain-free. A lower body mass index was the only significant factor associated with freedom from external drainage in post-hepatectomy biliary leakage (odds ratio 0.18, 95% confidence interval 0.05-0.65). Initial endoscopic treatment was effective for post-cholecystectomy biliary leakage, while approximately half of the patients with post-hepatectomy biliary leakage required multidisciplinary management. Achieving freedom from external drainage contributes to patients' quality of life and may be a predictor of treatment response after endoscopic therapy for postoperative biliary leakage.

Arterial complications after laparoscopic cholecystectomy: single centre experience

Laparoscopic cholecystectomy is one of the most common surgeries done in general surgical practice. Arterial complications after laparoscopic cholecystectomy are not uncommon and usually results due to iatrogenic injury. Mostly patients are managed by interventional radiological procedures, but very rarely we may have to resort to surgical procedures also. Our first patient a 40-year-old female patient presented with haemetemesis and malena. She was diagnosed with a right hepatic artery aneurysm following a laparoscopic cholecystectomy done 2 months back. Due to sudden haemodynamic instability, the patient underwent laparotomy aneurysmal excision and T tube drainage. Later T tube was removed. Another patient, a 41-year-old female patient presented to us with haemetemesis and malena 2 weeks after laparoscopic cholecystectomy. She developed a post-operative biliary leak and was managed with USG-guided pigtail drainage. She was later diagnosed with a GDA aneurysm along with mid-CBD transection. The patient was later managed with hepatico jejunostomy. Our third patient is a 52-year-old gentleman, underwent interval laparoscopic cholecystectomy following acute calculus cholecystitis. Intra operatively following profuse bleeding, RHA artery sectoral branch repair was done. Patient continued to have bleeding and he underwent emergency angioembolisation of right hepatic artery pseudo aneurysm. Arterial complications following laparoscopic cholecystectomy result either from direct arterial or combined Bilio arterial injuries. Interventional radiological procedures are still considered the standard of care in these situations. Surgical interventions hold equally good in ongoing bile leak and in failure of embolization techniques. Management strategy depends on the clinical profile of the patient and the injuries associated with it.

Do Biliary Leaks Alter the Risk of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis?

Do Biliary Leaks Alter the Risk of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis?

Multiple Graft Bile Ducts Do Not Affect the Postoperative Outcomes of Right Lobe Living Donor Liver Transplantation

Multiple graft duct openings are associated with a high incidence of biliary complications (BCs), and biliary reconstruction for multiple graft bile ducts (BDs) remains a surgical challenge during living donor liver transplantation (LDLT). In particular, biliary reconstruction using "high biliary radicals (HBR)" of recipients for multiple graft BDs has a high probability of BCs. Herein, we analyzed outcomes by retrospectively reviewing 283 patients who underwent right lobe LDLT from January 2013 to September 2019. In total, 112 LDLT procedures using grafts with multiple BDs have been performed under our policies. In recent cases with 2 orifices located on the same hilar plate, we did dunking with a mucosal eversion technique instead of ductoplasty. When 2 orifices are located far apart on different hilar plates, we attempted to perform separate duct-to-duct anastomosis (DDA) using HBR of the recipient instead of hepaticojejunostomy. Among patients with multiple graft BDs, 20 underwent ductoplasty, 50 were treated using dunking with mucosal eversion technique, and 40 underwent separate DDA using HBR (HBR group). The incidence rates of biliary leakage and stricture were 8.9% and 10.7% in the multiple BD group, respectively, congruent with the outcomes of the single BD group. In subgroup analysis, we compared clinical outcomes between the HBR and single BD groups; the incidence of BCs in the HBR group was 15.0%, comparable to that of the single BD group. In conclusion, multiple graft BDs do not negatively impact the BC rate compared with single-graft BD when applying our technique to prevent BCs.