Bilioenteric Anastomosis Research Articles

Robotic pancreaticoduodenectomy after open Roux-en-Y biliary-enteric anastomosis: Technical insights (with video)

TechniqueRobotic pancreaticoduodenectomy (RPD) presents a formidable surgical challenge for patients with a prior history of bilioenteric anastomosis. However, there are no reports in the literature of robotic pancreaticoduodenectomy after open bilioenteric anastomosis. This article offers a detailed description of the surgical technique employed in performing RPD on a patient who previously underwent open Roux-en-Y biliary–enteric anastomosis, aiming to treat a duodenal tumor. ResultsThe patient underwent a successful surgery with a total operation time of 320 min and an estimated blood loss of approximately 150 ml. Following the procedure, the patient experienced an uncomplicated recovery and was discharged from the hospital after a 14-day hospitalization period. Postoperative pathology revealed a moderately differentiated adenocarcinoma of the duodenum invading the entire layer of the bowel wall. ConclusionsRPD is a safe and viable option for patients with a history of complex abdominal surgery.

Less is more: The use of a single biodegradable stenting to treat biliary anastomotic strictures in pediatric liver transplantation.

To report our experience of using biodegradable biliary stents for anastomotic biliary strictures in pediatric liver transplant patients. Analysis of a retrospective data collection from January 2014 to January 2023, including all pediatric liver transplant recipients in our center treated for anastomotic biliary strictures with biodegradable biliary stents (BBS). In phase 1 (2014-2019), there was an initial percutaneous transhepatic cholangiography (PTC) with anastomotic dilatation followed two weeks after by a second PTC with BBS insertion. In phase 2 (2019-2023), the BDS were placed shortly after anastomotic biliary strictures dilatation, requiring only one PTC. All patients were followed up with routine tests and ultrasound. Forty-six anastomotic biliary strictures were diagnosed in 43 pediatric liver transplant recipients with a median of 6.7 months post-liver transplantation (0.1-246.8 months). Eight out of 46 anastomotic biliary strictures (17.4%) treated with biodegradable biliary stents relapsed (median recurrence time: 6.5 months; 1.6-17.0 months). Four resolved with further BBS placement; only four needed surgical revision (8.7%) after a median follow-up time of 43.9 months (0.3-106.3). There were no differences in anastomotic biliary strictures recurrence rate, time between stent placement and recurrence, or the presence of cholangitis based on whether the BBS was deployed in one or two steps. Patients with end-to-end anastomosis had a higher anastomotic biliary strictures recurrence (or 10.8; 1.4-81.3, p=0.008) than those with bilioenteric anastomosis. The use of biodegradable stents stents could be good option for treating anastomotic biliary strictures in pediatric liver transplant patients, with our series showing a success rate of over 90% and an average follow-up of 43.9 months.

Retrospective analysis of surgical management options of hepatolithiasis in a tertiary care centre in Bangladesh

Background: Hepatolithiasis (HL) is the presence of stones in the bile ducts proximal to the confluence of the hepatic ducts. It is endemic in the Asia-Pacific region. The etiology of hepatolithiasis is not fully understood but genetic, dietary and environmental factors are thought to be contributory. Malnutrition and low socioeconomic conditions are associated with a high incidence of intrahepatic stones. This study aimed to analyze the demographic and clinicopathological factors, appraise the role of surgical management and analyse the postoperative outcomes of HL in a tertiary care centre in Bangladesh. Methods: This study was conducted in the Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplant (HBPS & LT), BIRDEM General Hospital, Dhaka, Bangladesh. Retrospective data of all patients operated for HL from January 2011 to December 2022 were analyzed with regard to clinical parameters, biochemical parameters and different types of surgical management. Results: A total of 52 patients underwent surgical treatment for HL. Of the patients, 65.4% were female and 34.6% were male. Of the patients, 94.2% had abdominal pain, 57.7% had fever and 28.8% presented with jaundice. A total of 30.8% of patients had a history of previous biliary surgery. Liver atrophy was present in 38.5% of cases. Hepaticojejunostomy (HJ) alone was done in 36 (69.2%) patients, hepatic resection with bilioenteric anastomosis was done in 10 (19.2%) patients and hepatic resection with T-tube placement in common bile duct (CBD) done in 6 (11.5%) patients. Endoluminal access loop was done in 2 (3.8%) patients. On followup visits, 60% of patients were asymptomatic. There was no postoperative mortality. Conclusion: Results from present study revealed encouraging results with minimal post operative complications and no mortality. BIRDEM Med J 2024; 14(3): 137-142

A case series of prenatal hepatic hilar cyst in the presence of a gallbladder - navigating the dilemma between biliary atresia and choledochal cyst

BackgroundPrenatally diagnosed hepatic hilar cysts are a challenging finding for the clinician. They can either be a sign of cystic biliary atresia (BA) or a choledochal cyst (CC), two diagnoses with different postnatal management and prognosis. Based on a case report of four patients, we aim to propose a management algorithm for prenatally diagnosed “hepatic hilar cysts”.Case presentationA hepatic hilar cyst, ranging from 5 to 25 mm, was detected prenatally in all four girls confirmed postnatally along with the presence of a gallbladder. Stool color was normal until two weeks of life at which time the stool color became lighter, and the patients developed cholestasis. All were operated before seven weeks of life: Case 1 had a CC with patent but irregular intrahepatic bile ducts at intraoperative cholangiogram, and no communication with the duodenum. A Roux-en-Y bilioenteric anastomosis was performed. The cyst showed complete epithelial lining loss, and liver pathology showed BA features. Case 2 had the final diagnosis of cystic BA with patent but abnormal intrahepatic bile ducts. She underwent two operations: the first operation at four weeks as described for case 1, since intraoperative findings were similar, as was histology. As cholestasis increased postoperatively, she underwent a Kasai hepato-porto-enterostomy six weeks later, where distinct BA findings were found with complete scarring of the hilar plate. Case 3 had a cystic BA with the cyst located within the common bile duct and atretic bile ducts proximal to the porta hepatis. It exhibited no communication with the liver or duodenum. A Kasai operation was performed, with histology showing complete epithelial loss within the cyst wall and scarring of the hilar plate. Case 4 had a cystic BA presenting a completely obliterated hepatic duct with the cyst lying within the common bile duct. A Kasai procedure was performed. Histology showed a common bile duct with a residual lumen of 0.1 mm.ConclusionsThe spectrum of disease from CC to BA in the setting of a prenatally discovered hepatic hilar cyst is emphasized. Even if cholangiogram differentiates most patients with BA from those with CC, caution is advised for transitional types.

Combined endoscopic drainage for afferent loop obstruction and bilioenteric anastomosis stricture in a patient after pancreatoduodenectomy.

Combined endoscopic drainage for afferent loop obstruction and bilioenteric anastomosis stricture in a patient after pancreatoduodenectomy.

Outcomes of endoscopic ultrasound-guided gallbladder drainage: A multicenter study from India (with video).

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) offers a safe and minimally invasive alternative for percutaneous cholecystostomy (PCC) in acute cholecystitis patients with high-surgical risk. Additionally, EUS-GBD serves as a rescue biliary drainage in malignant distal biliary obstruction. Despite its widespread application, data within the Indian context remains sparse. This study aims to report the outcomes of EUS-GBD through the first multi-center study from India. We retrospectively analyzed patients undergoing EUS-GBD at six tertiary care centers of India from March 2022 to November 2023. EUS-GBD was performed by free hand or over-the-guidewire technique with lumen-apposing metal stent (LAMS) or large caliber metal stent (LCMS). The primary outcome was technical success (defined as successful deployment of stent between gallbladder and stomach/duodenal lumen). The secondary outcomes were clinical success (defined as resolution of symptoms of acute cholecystitis and more than > 50% reduction in bilirubin level within two weeks in distal biliary obstruction), adverse event rate, 30-day mortality rate and 90-day reintervention rate. Total29 patients (mean age 65.86 ± 12.91, 11 female) underwent EUS-GBD. The indication for EUS-GBD were acute cholecystitis (79.31%) and rescue biliary drainage for malignant distal biliary obstruction (20.69%). LAMS was deployed in 92.86%, predominantly by free-hand technique (78.57%). Technical and clinical success rates were 96.55% and 82.75%, respectively. Adverse events occurred in 27.59% patients, with severe adverse events (bile leak and bleeding) being uncommon (10%). Both 30-day mortality rate and 90-day reintervention rate were 13.79% in patients. Cholecysto-duodenal fistula facilitated cholecystoscopic intervention and stone removal in one patient and transgastric EUS-GBD did not hamper bilio-enteric anastomosis during Whipple surgery in two patients. EUS-GBD is a safe and effective technique for managing acute cholecystitis in high-risk patients and for biliary drainage in cases with malignant distal biliary obstruction.

Hepatobiliary Infection after Transjugular Intrahepatic Portosystemic Shunt Creation in Patients with Prior Biliary Intervention: A Multi-Institution Retrospective Study

PurposeTo estimate the risk of hepatobiliary infection, including endoTIPSitis, liver abscesses, and cholangitis, after transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with prior biliary intervention. Materials and MethodsThis multi-institution, retrospective study identified 76 patients (n = 48 males; mean age, 54.9 years; mean Model for End-stage Liver Disease [MELD] score, 13.2; n = 45 for ascites and n = 23 for varices; n = 31 with prior liver transplantation) among 2,130 (3.6%) undergoing TIPS creation who had prior biliary intervention (n = 19 bilioenteric anastomoses, n = 35 sphincterotomies, n = 28 internal plastic stent placements, n = 4 internal metal stent placements, and n = 6 percutaneous biliary drain placements). The baseline risk of post–TIPS creation hepatobiliary infection was estimated from a control group of 1,202 TIPS creation procedures in patients without prior biliary intervention. ResultsEleven (14.5%) of 76 patients developed hepatobiliary infection after TIPS creation, including 7 with endoTIPSitis, 4 with hepatic abscesses, and 2 with cholangitis. The 30-day risk of infection was 10.9% (95% confidence interval [CI], 3.5%–17.8%), significantly higher than the 0.4% risk (95% CI, 0.1%–0.8%) observed in patients without prior biliary intervention (hazard ratio [HR], 25.56; 95% CI, 8.36–78.13; P < .001). All types of biliary intervention were associated with increased risk of infection, with bilioenteric anastomoses conferring the highest risk. Paradoxically, among patients with prior biliary intervention, use of postprocedural antibiotic prophylaxis was associated with an increased infection risk (HR, 19.85; 95% CI, 2.44–161.50; P = .005). Microbial culture data showed high rates of Enterococcus, Klebsiella, and Candida species. ConclusionsPrior biliary intervention was associated with a 10.9% risk of hepatobiliary infection, including endoTIPSitis, liver abscess, and cholangitis, within 30 days after TIPS creation.

Robotic Right Hepatectomy with En Bloc Caudatectomy for Bismuth IIIa Hilar Cholangiocarcinoma: A Video Demonstration of Left-Liver-First Anterior Radical Modular Orthotopic Right Hemihepatectomy.

Minimally invasive resection for perihilar cholangiocarcinoma is a complicated and technically demanding surgical procedure. Radical surgical resection is regarded as the best treatment for hepatic hilar cholangiocarcinoma.1,2 Right hepatectomy with caudate lobe resection is necessary as the treatment for bismuth IIIa hilar cholangiocarcinoma.3 The left-liver-first anterior radical modular orthotopic right hemihepatectomy (LARMORH), which can simplify surgical steps and decrease procedural difficulty, may be a better choice for Bismuth IIIa hilar cholangiocarcinoma.4 However, there are no reports of this approach using robotic technique for this operation. We will provide a detailed introduction to this method through this video. A 45-year-old female patient was diagnosed with a hilar cholangiocarcinoma. Following a 7-day percutaneous biliary drainage of the left intrahepatic bile duct and obtaining informed consent, we performed a robotic radical resection of the HCCA using the LARMORH approach. The patient was positioned supine with the entire bed elevated 20° and tilted 15° to the left. Trocars were placed in position (Fig. 1). After entering the abdominal cavity, it was explored for tumor metastasis. The surgery adopted a left approach, initially exploring the left hepatic artery and vein to further assess resectability. After confirming resectability, the right hepatic artery and gastroduodenal artery (GDA) were dissected. The common bile duct was dissected and transected at its distal end, ensuring R0 surgical margins. Lymph nodes were cleared from the foot side to the head side, confirming the metastasis to the lymph node group 13a, so we further cleared the group 16 and 9 lymph nodes.5 Subsequently, we approached the resection of the right half and the entire caudate lobe with the reverse thinking of left hepatic resection mode, preserving only the left branch of the portal vein and left hepatic artery, and dissecting the liver tissue along the resection plane of the left liver. After transection of the left hepatic duct, the activity space of the left liver was larger and the caudate lobe could be better exposed. The Spiegel lobe was lifted to the right in a "turn the page" fashion for in situ resection of the entire caudate lobe and the right half of the liver. Finally, a bilioenteric anastomosis was performed using the Roux-en-Y method. Robotic right hepatectomy with caudate lobectomy was successfully performed in 450 min, with an estimated blood loss of 200ml. The histological grading was determined as T1aN1M0 (stage IIIB) on the basis of postoperative pathological biopsy results. The patient achieved a satisfactory postoperative recovery and was discharged on the 14th postoperative day without any major complications. Following the operation, the patient received capecitabine chemotherapy according to the Chinese Society of Clinical Oncology (CSCO) criteria. Since September 2022, our team has completed three radical resections for Bismuth IIIa HCCA using this technique. All patients achieved a satisfactory postoperative recovery without any further complications. Robotic left-liver-first anterior radical modular orthotopic right hemihepatectomy for Bismuth IIIa HCCA is both safe and feasible. This method may provide a new surgical approach for patients with type IIIA HCCA or liver diseases requiring right hemihepatectomy combined with total caudate lobectomy.

Clinical characteristics of pyogenic liver abscess with and without biliary surgery history: a retrospective single-center experience

Background & aimsPyogenic liver abscess (PLA) is a common hepatobiliary infection that has been shown to have an increasing incidence, with biliary surgery being identified as a trigger. Our aim was to investigate the clinical characteristics and treatments of PLA patients with and without a history of biliary surgery (BS).MethodsThe study included a total of 353 patients with PLA who received treatment at our hospital between January 2014 and February 2023. These patients were categorized into two groups: the BS group (n = 91) and the non-BS group (n = 262). In the BS group, according to the anastomosis method, they were further divided into bilioenteric anastomoses group (BEA, n = 22) and non-bilioenteric anastomoses group (non-BEA, n = 69). Clinical characteristics were recorded and analyzed.ResultsThe percentage of PLA patients with BS history was 25.78%. The BS group exhibited elevated levels of TBIL and activated APTT abnormalities (P = 0.009 and P = 0.041, respectively). Within the BS group, the BEA subgroup had a higher prevalence of diabetes mellitus (P < 0.001) and solitary abscesses (P = 0.008) compared to the non-BEA subgroup. Escherichia coli was more frequently detected in the BS group, as evidenced by positive pus cultures (P = 0.021). The BS group exhibited reduced treatment efficacy compared to those non-BS history (P = 0.020). Intriguingly, the BS group received a higher proportion of conservative treatment (45.05% vs. 21.76%), along with reduced utilization of surgical drainage (6.59% vs. 16.41%).ConclusionsPatients with BS history, especially those who have undergone BEA, have an increased susceptibility to PLA formation without affecting prognosis.

Optimized reusable modular 3D-printed models of choledochal cyst to simulate laparoscopic and robotic bilioenteric anastomosis

Laparoscopic and robotic surgery is a challenge to the surgeon's hand–eye coordination ability, which requires constant practice. Traditional mentor training is gradually shifting to simulation training based on various models. Laparoscopic and robotic bilioenteric anastomosis is an important and difficult operation in hepatobiliary surgery. We constructed and optimized the reusable modular 3D-printed models of choledochal cyst. The aim of this study was to verify the ability of this optimized model to distinguish between surgeons with different levels of proficiency and the benefits of repeated practice. A total of 12 surgeons with different levels participated in the study. Operation completion time and OSATS score were recorded. The model was validated by Likert scale. Surgeons were shown the steps and contents before performing laparoscopic or robotic bilioenteric anastomosis using the model. Surgeons with different levels of experience showed different levels when performing laparoscopic bilioenteric anastomosis on this model. Repeated training can significantly shorten the time of laparoscopic bilioenteric anastomosis and improve the operation scores of surgeons with different levels of experience. At the same time, preliminary results have shown that the performance of surgeons on the domestic robotic platform was basically consistent with their laparoscopic skills. This model may distinguish surgeons with different levels of experience and may improve surgical skills through repeated practice. It is worth noting that in order to draw more reliable conclusions, more subjects should be collected and more experiments should be done in the future.

Simulation training of laparoscopic biliary-enteric anastomosis with a three-dimensional-printed model leads to better skill transfer: a randomized controlled trial.

A new simulation model and training curriculum for laparoscopic bilioenteric anastomosis has been developed. Currently, this concept lacks evidence for the transfer of skills from simulation to clinical settings. This study was conducted to determine whether training with a three-dimensional (3D) bilioenteric anastomosis model result in greater transfer of skills than traditional training methods involving video observation and a general suture model. Fifteen general surgeons with no prior experience in laparoscopic biliary-enteric anastomosis were included in this study and randomised into three training groups: video observation only, practice using a general suture model, and practice using a 3D-printed biliary-enteric anastomosis model. Following five training sessions, each surgeon was asked to perform a laparoscopic biliary-enteric anastomosis procedure on an isolated swine organ model. The operative time and performance scores of the procedure were recorded and compared among the three training groups. The operation time in the 3D-printed model group was significantly shorter than the suture and video observation groups ( P =0.040). Furthermore, the performance score of the 3D-printed model group was significantly higher than those of the suture and video observation groups ( P =0.001). Finally, the goal score for laparoscopic biliary-enteric anastomosis in the isolated swine organ model was significantly higher in the 3D model group than in the suture and video observation groups ( P =0.004). The utilisation of a novel 3D-printed model for simulation training in laparoscopic biliary-enteric anastomosis facilitates improved skill acquisition and transferability to an animal setting compared with traditional training techniques.

Continuous versus interrupted anastomotic technique for the hepaticojejunostomy: a prospective cohort study.

Interrupted sutures is the gold standard technique of hepaticojejunostomy (HJ) for bilioenteric anastomosis. This study compares the safety and early complications of continuous and interrupted suture HJ. A prospective study involving all elective HJ between September 2019 and June 2021 was conducted. Patients with type IV or V biliary strictures, duct diameter less than 8mm and/or associated vascular injury, and bilateral HJ were excluded. The study patients were divided into two random groups; interrupted and continuous anastomotic technique. Patient demographics, preoperative parameters including pathology (benign vs. malignant), HJ leak, suture time, and postoperative morbidity were recorded. Total 34 patients were enroled. Eighteen (52.9%) were into interrupted and 16 (47.1%) patients into the continuous group. Both the groups were comparable with regards to demographics, haemoglobin, serum albumin, preoperative cholangitis and biliary stenting. Total three (8.8%) patients in the entire study developed bile leak; interrupted-2 and continuous-1, which was not significant statistically (P=1.0). Similarly, total number of sutures used and the mean operating time to complete anastomosis in the continuous group was significantly lesser than the interrupted group (2.3±0.5 versus 9.6±1.6, P<0.001) and (16.2±3.1 versus 38.6±9.2min, P<0.001), respectively. There were three (18.8%) re-exploration in the continuous anastomotic technique. Among them, only one re-operation was due to HJ anastomosis failure without mortality, remaining had re-exploration for bleeding (non-HJ). Both the techniques is safe with comparable morbidity. Further, continuous has an added advantage of decreased anastomotic time and cost.

Cancer is a risk factor of bile leakage following bilio-enteric anastomosis: results of a prospective study including 79 patient

Cancer is a risk factor of bile leakage following bilio-enteric anastomosis: results of a prospective study including 79 patient

An alternative method in the diagnosis of intrabiliary lesions: Percutaneous endobiliary brush biopsy.

Biliary strictures can occur as a result of various benign or malignant processes. The aim of this study is to evaluate the effectiveness and reliability of percutaneous endobiliary brush biopsy in the diagnosis of intrabiliary lesions. This retrospective, single-center study was conducted between January 2022 and April 2023, involving a total of 16 patients. Of the patients, 10 were male (62.5%), and 6 were female (37.5%). The average age of the patients was 68.1±8. All patients underwent the procedure using an endobiliary biopsy brush under ultrasound and fluoroscopic guidance. Technical success was achieved in all patients (100%). Cell detection was not observed in biopsy samples from 2 patients (12.5%), resulting in a diagnostic success rate of 87.5%. Access was made to the right biliary system in 14 patients (87.5%) and to the left biliary system in 2 patients (12.5%). Biopsy locations included the common bile duct in 12 patients (75%), hepatic hilum in 2 patients (12.5%), and bilioenteric anastomosis line in 2 patients (12.5%). The mean fluoroscopy time was 16.2±7.1 minutes. The average radiation dose was 660±370 mSv. Pathological diagnosis revealed malignancy in 8 patients (50%) and benign findings in 6 patients (37.5%). Liver abscess requiring drainage developed in 2 patients (12.5%). Percutaneous endobiliary brush biopsy performed under imaging guidance is an effective and reliable method for the diagnosis of biliary lesions.

Treatment of failed bilioenteric anastomosis after bile duct injuries in a tertiary care center of Nepal

Treatment of failed bilioenteric anastomosis after bile duct injuries in a tertiary care center of Nepal

Mirizzi Syndrome-The Past, Present, and Future.

Mirizzi syndrome is a complication of gallstone disease caused by an impacted gallstone in the infundibulum of the gallbladder or within the cystic duct, causing chronic inflammation and extrinsic compression of the common hepatic duct or common bile duct. Eventually, mucosal ulceration occurs and progresses to cholecystobiliary fistulation. Numerous systems exist to classify Mirizzi syndrome, with the Csendes classification widely adopted. It describes five types of Mirizzi syndrome according to the presence of a cholecystobiliary fistula and its corresponding severity, and whether a cholecystoenteric fistula is present. The clinical presentation of Mirizzi syndrome is non-specific, and patients typically have a longstanding history of gallstones. It commonly presents with obstructive jaundice, and can mimic gallbladder, biliary, or pancreatic malignancy. Achieving a preoperative diagnosis guides surgical planning and improves treatment outcomes. However, a significant proportion of cases of Mirizzi syndrome are diagnosed intraoperatively, and the presence of dense adhesions and distorted anatomy at Calot's triangle increases the risk of bile duct injury. Cholecystectomy remains the mainstay of treatment for Mirizzi syndrome, and laparoscopic cholecystectomy is increasingly becoming a viable option, especially for less severe stages of cholecystobiliary fistula. Subtotal cholecystectomy is feasible if total cholecystectomy cannot be performed safely. Additional procedures may be required, such as common bile duct exploration, choledochoplasty, and bilioenteric anastomosis. Conclusions: There is currently no consensus for the management of Mirizzi syndrome, as the management options depend on the extent of surgical pathology and availability of surgical expertise. Multidisciplinary collaboration is important to achieve diagnostic accuracy and guide treatment planning to ensure good clinical outcomes.

Beyond the gut: spectrum of magnetic surgery devices.

Since the 1970s, magnetic force has been used to augment modern surgical techniques with the aims of minimizing surgical trauma and optimizing minimally-invasive systems. The majority of current clinical applications for magnetic surgery are largely centered around gastrointestinal uses-such as gastrointestinal or bilioenteric anastomosis creation, stricturoplasty, sphincter augmentation, and the guidance of nasoenteric feeding tubes. However, as the field of magnetic surgery continues to advance, the development and clinical implementation of magnetic devices has expanded to treat a variety of non-gastrointestinal disorders including musculoskeletal (pectus excavatum, scoliosis), respiratory (obstructive sleep apnea), cardiovascular (coronary artery stenosis, end-stage renal disease), and genitourinary (stricture, nephrolithiasis) conditions. The purpose of this review is to discuss the current state of innovative magnetic surgical devices under clinical investigation or commercially available for the treatment of non-gastrointestinal disorders.

Performance evaluation of a North American center using the established global benchmark for laparoscopic liver resections: A retrospective study

BackgroundThe global benchmark cut-offs were set for laparoscopic liver resection procedures: left lateral sectionectomy, left hepatectomy, and right hepatectomy. We aimed to compare the performance of our North American center with the established global benchmarks. MethodsThis is a single-center study of adults who underwent laparoscopic liver resection between 2010 to 2022 at the Toronto General Hospital. Fourteen benchmarking outcomes were assessed: operation time, intraoperative blood transfusion, estimated blood loss, blood loss ≥500 mL, blood loss ≥1000mL, open-conversion, postoperative length of stay, return to operation, postoperative morbidity, postoperative major-morbidity, 30-day mortality, 90-day mortality, R1 resection, and failure to rescue. Low-risk benchmark cases were defined as follows: patients aged 18 to 70 years, American Society of Anesthesiologist score ≤ 2, tumor size <10 cm, and Child–Pugh score ≤A. Cases involving bilio-enteric anastomosis, hilar dissection, or concomitant major procedures were excluded from the low-risk category. Cases that did not meet the criteria for low-risk selection were considered high-risk cases. ResultsA total of 178 laparoscopic liver resection cases were analyzed (109 left lateral sectionectomies, 45 left hepatectomies, 24 right hepatectomies). Forty-four (25%) cases qualified as low-risk cases (23 left lateral sectionectomies, 16 left hepatectomies, 5 right hepatectomies). The postoperative major morbidity and 90-day mortality after left lateral sectionectomy, left hepatectomy, and right hepatectomy for the low-risk cases were 0%, 0%, and 0%, and 0%, 0%, and 0%, respectively. For the high-risk cases post-2017, the outcomes in the same order were 0%, 0%, and 12%; 0%, 0%, and 0%, respectively. For the high-risk cases operated pre2017, the outcomes in the same order were 9%∗, 16%∗, and 18%; 2%∗, 0%, and 9%∗ (asterisks indicate not meeting the global cut-off), respectively. ConclusionA North American center was able to achieve outcomes comparable to the established global benchmark for laparoscopic liver resection.

Impact of sarcopenic obesity on post-hepatectomy bile leakage for hepatocellular carcinoma.

Post-hepatectomy bile leakage (PHBL) is a potentially fatal complication that can arise after hepatectomy. Previous studies have identified obesity as a risk factor for PHBL. In this study, we investigated the impact of sarcopenic obesity on PHBL in hepatocellular carcinoma (HCC) patients. In total, we enrolled 409 patients who underwent hepatectomy without bilioenteric anastomosis for HCC between January 2010 and August 2021. Patients were grouped according to the presence or absence of PHBL. Patient characteristics, including body mass index and sarcopenic obesity, were then analyzed for predictive factors for PHBL. Among the 409 HCC patients included in the study, 39 developed PHBL. Male sex, hypertension, cardiac disease, white blood cell counts, the psoas muscle area, and visceral fat area, and intraoperative blood loss were significantly increased in the PHBL (+) group compared with the PHBL (-) group. Multivariate analysis showed that the independent risk factors for the occurrence of PHBL were intraoperative blood loss ≥370 mL and sarcopenic obesity. Our results show that it is important to understand whether a patient is at high risk for PHBL prior to surgery and to focus on reducing intraoperative blood loss during surgery for patients with risk factors for PHBL.

Stented Versus Non-stented Bilio-Enteric Anastomosis in Hepatobiliary Unit, Minia University Hospital

Stented Versus Non-stented Bilio-Enteric Anastomosis in Hepatobiliary Unit, Minia University Hospital