Major Hepatobiliary Surgery Research Articles

The safety and risk factors of major hepatobiliary pancreatic surgery in patients older than 80 years.

PurposeRecently, the number of elderly patients has increased due to a longer life expectancy. Among these elderly patients, more octogenarians will be diagnosed with major hepatobiliary pancreatic (HBP) diseases. Therefore, we need to evaluate the safety and risk factors of major HBP surgery in patients older than 80 years.MethodsFrom January 2000 to April 2015, patients who underwent major HBP surgery were identified. The patients were divided into 2 groups according to their age at the time of surgery: Group O (≥80 years) and group Y (<80 years). The patient characteristics and intra- and postoperative outcomes were retrospectively investigated in the 2 groups.ResultsThe median age was 84 years (range, 80–95 years) in group O and 61 years (range, 27–79 years) in group Y. group O had worse American Society of Anesthesiologists (ASA) physical status (ASA ≥ III: 23% vs. 7%, P = 0.002) and was associated with a higher rate of hypertension and heart problems as comorbidities. There were significant differences in albumin and BUN, favoring group Y. The length of intensive care unit stay was longer in group O, whereas the overall complication and mortality rates did not show statistical difference. But, there was a significant difference in systemic complication of both Clavien-Dindo classification grade ≥II and ≥III as complications were divided into surgical site complication and systemic complication.ConclusionMajor HBP surgery can be performed safely in patients older than 80 years if postoperative management is appropriately provided.

Multidisciplinary Treatment of Cystic Fibrosis-Related Recurrent Pyogenic Cholangitis (CF-RPC).

As the survival of cystic fibrosis patients improves due to better treatment of its pulmonary manifestations, the management of hepatobiliary complications becomes increasingly vital. While focal biliary cirrhosis is common, large duct manifestations are less frequently encountered. We prospectively evaluated cases of large bile duct disease in a large adult cystic fibrosis practice at the Keck Hospital of the University of Southern California. Over a 5-year period, six patients presented with cholangiectasia, hepatolithiasis, and strictures. Their clinical presentation and course closely resembled recurrent pyogenic cholangitis (RPC). Treatment of cholangitis and strictures was primarily by endoscopic retrograde cholangiopancreatography, but major hepatobiliary surgery following pulmonary optimization was required in 33 %. In adult populations, CF-RPC may not be as unusual as previously reported and recognition allows optimal endoscopic, medical, and surgical management.

The incidence of clinically significant venous thromboembolism in an Asian population after major hepatobiliary and pancreatic surgery

Introduction: The incidence of venous thromboembolism (VTE) is not well defined in Asian population after major hepatobiliary and pancreatic (HPB) surgery. The use of pharmacological prophylaxis is debatable due to postoperative coagulopathy. Aim: To determine the incidence of clinically significant VTE events in Asian undergoing major HPB surgery. Methods: A retrospective review of patients undergoing major HPB surgery between January 2010 to August 2013 at Tan Tock Seng Hospital, Singapore was conducted. Clinical notes and radiology reports were reviewed to screen for patients who developed VTE. A secondary endpoint was 30-day and 90-day mortality. Results: 224 patients had major HPB surgery with median age of 61 years and BMI of 22.3. 143 patients were male. Majority of the patients were Chinese and most underwent open hepatic surgery for malignancy. A few had a past history of VTE. No patient developed DVT, whilst a single patient was diagnosed with pulmonary embolus. There were two unexpected deaths within 90 days of surgery and neither appeared to be VTE-related. Statistical tests comparing our results with reported baseline VTE risk in literature and risk with chemoprophylaxis would suggest the low incidence found in this study was comparable to Western patients given chemoprophylaxis. Conclusion: The risk of VTE appears low in Asian patients undergoing major HPB surgery. Hence, one must consider if the benefits of low molecular weight heparin does indeed outweigh the risks.

Post-operative depletion of platelet count is associated with anastomotic insufficiency following intrahepatic cholangiojejunostomy: a case-control study from the results of 220 cases of intrahepatic cholangiojejunostomy.

BackgroundPost-operative anastomotic insufficiency following major hepato-biliary surgery has significant impacts on the post-operative course. Recent reports have revealed that platelets play an important role in liver regeneration and wound healing. From these experimental and clinical results on platelet function, we hypothesized that post-operative platelet depletion (to <10 × 104/μL) would be associated with delayed liver regeneration as well as anastomotic insufficiency of intrahepatic cholangiojejunostomy. However, little information is available regarding correlations between platelet count and these complications. The purposes of the present study were, firstly, to evaluate the incidence of anastomotic insufficiency following intrahepatic cholangiojejunostomy and, secondly, to evaluate whether platelet depletion represents a risk factor for anastomotic insufficiency in intrahepatic cholangiojejunostomy.MethodsParticipants in this study comprised 220 consecutive patients who underwent intrahepatic cholangiojejunostomy following hepato-biliary resection for biliary malignancies between September 1998 and December 2010. Anastomotic insufficiency was confirmed by cholangiographic demonstration of leakage from the anastomosis using contrast medium introduced via a biliary drainage tube or prophylactic drain placed during surgery.ResultsAnastomotic insufficiency of the intrahepatic cholangiojejunostomy occurred in 13 of 220 patients (6%). Thirteen of the 220 patients, including one with anastomotic insufficiency, died during the study. Uni- and multivariate analyses both revealed that platelet depletion on post-operative day 1 (<10 × 104/μL) correlated with anastomotic insufficiency.ConclusionPost-operative platelet depletion was closely associated with anastomotic insufficiency following intrahepatic cholangiojejunostomy. This correlation has been established, but the underlying mechanisms have not.

A non-invasive screening technique for type 1 autoimmune pancreatitis.

IntroductionType 1 autoimmune pancreatitis (AIP) is the pancreatic manifestation of a systemic fibroinflammatory IgG4-related disease. Accurate diagnosis of AIP can avoid major hepatobiliary and pancreatic surgery as it respond dramatically to corticosteroid therapy.AimThis research investigated the feasibility of using peripheral blood cell immunohistochemistry, serum IgG4, T-cell receptor (TCR) and serum isoelectric focusing electrophoresis in the screening of type 1 autoimmune pancreatitis (AIP).Material and methodsThe peripheral blood from 3 type 1 AIP patients, 10 pancreatic cancer patients and 40 normal controls was collected. Sediment smears were jointly incubated with anti-IgG4 and anti-IgG. The percentage of IgG4/IgG positive cells was counted and serum TCR and IgG4 were detected through the whole process. After serum isoelectric focusing electrophoresis, anti-IgG4 and anti-IgG were used to confirm the components of serum.ResultsIn the serum isoelectric focusing electrophoresis, IgG4 and IgG strips showed mirrored distribution in type 1 AIP patients, while there were no strips in the normal controls and pancreatic cancer. Compared with pancreatic tumor patients and healthy controls, serum TCR was significant increased in AIP. The percentage of IgG4/IgG positive cells of peripheral blood cell immunohistochemistry was related to serum IgG4 and hormone therapy reactions.ConclusionsPeripheral blood cell immunohistochemistry, serum IgG4, TCR and serum isoelectric focusing electrophoresis is suitable for the screening of type 1 AIP and monitoring its response assessment.

Factors associated with failure of enhanced recovery protocol in patients undergoing major hepatobiliary and pancreatic surgery: a retrospective cohort study

ObjectiveThis study examined the risk factors associated with failure of enhanced recovery protocol after major hepatobiliary and pancreatic (HBP) surgery.Setting and participantsA retrospective cohort of 194 adult patients undergoing major...

Pressurized Pulse Irrigation with Saline Reduces Surgical‐site Infections following Major Hepatobiliary and Pancreatic Surgery: Randomized Controlled Trial

Surgical site infections (SSI) are a significant cause of postoperative morbidity. Pressurized pulse irrigation of subcutaneous tissues may lower infection rates by aiding in the debridement of necrotic tissue and reducing bacterial counts compared to simply pouring saline into the wound. A total of 128 patients undergoing laparotomy extending beyond 2 h were randomized to treatment of wounds by pressurized pulse lavage irrigation (<15 psi) with 2 L normal saline (pulse irrigation group), or to standard irrigation with 2 L normal saline poured into the wound, immediately prior to skin closure (standard group). Only elective cases were included, and all cases were performed within a specialized hepatobiliary and pancreatic surgery unit. There were 62 patients managed by standard irrigation and 68 were managed by pulse irrigation. The groups were comparable in most aspects. Overall there were 16 (13 %) SSI. Significantly fewer SSI occurred in the pulse irrigation group [4 (6 %) vs. 12 (19 %); p = 0.032]. On multivariate analysis, the use of pulse irrigation was the only factor associated with a reduction in SSI with an odds ratio (OR) of 0.3 [95 % confidence interval (95 % CI) 0.1-0.8; p = 0.031]. In contrast, hospital length of stay of greater than 14 days was associated with increased infections with an OR of 7.6 (95 % CI 2.4-24.9; p = 0.001). Pulse irrigation of laparotomy wounds in operations exceeding 2 h duration reduced SSI after major hepatobiliary pancreatic surgery. (Australian New Zealand Clinical Trials Registry, ACTRN12612000170820).

Partial portal vein arterialization in acute liver failure

Experimental studies have shown that increasing the oxygen supply to the liver through partial portal vein arterialization (PPVA) enhances liver regeneration after extensive liver resection or drug intoxication. In the last two decades, several PPVA procedures were performed in humans with the aim to prevent or treat acute liver failure (ALF) following major hepatobiliary surgery or other etiology. The aim of this review was to analyze literature data on PPVA and report our experimental and clinical experience of this procedure. In this setting, we report our positive experience in the realization and clinical application of an extracorporeal device able to increase the oxygenated blood delivered to the liver through the umbilical vein and to support liver function in a man subjected to an extended liver resection. PPVA procedure has shown promising results in the treatment of ALF following major hepatobiliary surgery or from other etiology. Moreover, less invasive approaches to PPVA demonstrated to be safe and efficacy. It is clear that further investigations must be done to fully understand the potentiality of PPVA as a strategy to treat ALF.

Cardiorespiratory Fitness Predicts Mortality and Hospital Length of Stay After Major Elective Surgery in Older People

This study aimed to define the relationship between cardiorespiratory fitness and age in the context of postsurgery mortality and morbidity in older people. Postsurgery mortality and morbidity increase with age. Cardiorespiratory fitness also declines with age, and the independent and linked associations between cardiorespiratory fitness and age on postsurgical mortality and morbidity remain to be determined. An unselected consecutive group of 389 adults with a mean age of 66 years (range 26-86 years) underwent cardiorespiratory exercise testing before major hepatobiliary surgery at a single center. Mortality and critical care unit and hospital lengths of stay were collected from patient records. Primary outcomes were in-hospital all-cause mortality after surgery and hospital and critical care lengths of stay. Anaerobic threshold was the most significant independent predictor for postoperative mortality (P = 0.003; β = -0.657 and odds ratio = 0.52) in 18 of 389 (4.6%) patients who died during their in-hospital stay. Age was not a significant predictor in this model. Older people with normal cardiorespiratory fitness spent the same number of days in the hospital or critical care unit as younger people with similar cardiorespiratory fitness (13 vs 12; P = 0.08 and 1 vs 1; P = 0.103). Patients older than 75 years with low cardiorespiratory fitness spent a median of 11 days longer in hospital (23 vs 12; P < 0.0001) and 2 days longer in critical care (2.9 vs 0.9; P < 0.0001) when compared with patients with adequate cardiorespiratory fitness. Cardiorespiratory fitness is an independent predictor of mortality and length of hospital stay and provides significantly more accurate prognostic information than age alone. Clinicians should consider both the prognostic value of cardiorespiratory testing and techniques to preserve cardiorespiratory function before elective surgery in older people.

Immunosuppression following surgical and traumatic injury

Severe sepsis and organ failure are still the major causes of postoperative morbidity and mortality after major hepatobiliary pancreatic surgery. Despite recent progress in understanding the immune conditions of abdominal sepsis, the postoperative incidence of septic complications after major visceral surgery remains high. This review focuses on the clinical and immunological parameters that determine the risk of the development and lethal outcome of postoperative septic complication following major surgery and trauma. A review of the literature indicates that surgical and traumatic injury profoundly affects the innate and adaptive immune responses, and that a marked suppression in cell-mediated immunity following an excessive inflammatory response appears to be responsible for the increased susceptibility to subsequent sepsis. The innate and adaptive immune responses are initiated and modulated by pathogen-associated molecular-pattern molecules and by damage-associated molecular-pattern molecules through the pattern-recognition receptors. Suppression of cell-mediated immunity may be caused by multifaceted cytokine/inhibitor profiles in the circulation and other compartments of the host, excessive activation and dysregulated recruitment of polymorphonuclear neutrophils, induction of alternatively activated or regulatory macrophages that have anti-inflammatory properties, a shift in the T-helper (Th)1/Th2 balance toward Th2, appearance of regulatory T cells, which are potent suppressors of the innate and adaptive immune system, and lymphocyte apoptosis in patients with sepsis. Recent basic and clinical studies have elucidated the functional effects of surgical and traumatic injury on the immune system. The research studies of interest may in future aid in the selection of appropriate therapeutic protocols.

Oblique sub‐costal transversus abdominis plane (TAP) catheters: an alternative to epidural analgesia after upper abdominal surgery

The authors present three cases where catheters placed in the oblique sub-costal transversus abdominis plane provided prolonged analgesia after upper abdominal surgery. Patient 1 was admitted with severe sepsis following major hepatobiliary surgery. Bilateral catheters facilitated weaning from mechanical ventilation and provided adequate analgesia for 4 days. Patient 2 underwent emergency laparotomy for intestinal obstruction having refused consent for epidural analgesia. The transversus abdominis plane catheters provided a significant opioid sparing effect. A unilateral catheter offered rescue analgesia in patient 3 when the epidural catheter was displaced. We put forward a case for oblique sub-costal transversus abdominis plane catheters as an alternative to epidural analgesia after upper abdominal surgery.

Managing injuries of hepatic duct confluence variants after major hepatobiliary surgery: An algorithmic approach

To investigate injuries of anatomy variants of hepatic duct confluence during hepatobiliary surgery and their impact on morbidity and mortality of these procedures. An algorithmic approach for the management of these injuries is proposed. During a 6-year period 234 patients who had undergone major hepatobiliary surgery were retrospectively reviewed in order to study postoperative bile leakage. Diagnostic workup included endoscopic and magnetic retrograde cholangiopancreatography (E/MRCP), scintigraphy and fistulography. Thirty (12.8%) patients who developed postoperative bile leaks were identified. Endoscopic stenting and percutaneous drainage were successful in 23 patients with bile leaks from the liver cut surface. In the rest seven patients with injuries of hepatic duct confluence, biliary variations were recognized and a stepwise therapeutic approach was considered. Conservative management was successful only in 2 patients. Volume of the liver remnant and functional liver reserve as well as local sepsis were used as criteria for either resection of the corresponding liver segment or construction of a biliary-enteric anastomosis. Two deaths occurred in this group of patients with hepatic duct confluence variants (mortality rate 28.5%). Management of major biliary fistulae that are disconnected from the mainstream of the biliary tree and related to injury of variants of the hepatic duct confluence is extremely challenging. These patients have a grave prognosis and an early surgical procedure has to be considered.

Portal Vein Arterialization in Hepatobiliary Surgery and Liver Transplantation

We reviewed the literature reports and our personal experience on partial portal vein arterialization (PPVA) to prevent and treat acute liver failure (ALF) following major hepatobiliary surgery or another etiology. Experimental studies in rats have assessed the efficacy of PPVA in treatment of ALF induced by extended resections in normal or fatty livers or in toxic carbon-tetrachloride damage. The treated groups showed greater survival and faster recovery of liver function. Among 11 clinical cases reported in the literature, PPVA was performed in four cases to prevent and in seven cases to treat ALF. Eight patients survived, showing rapid recovery of liver function and resolution of the clinical condition. This relatively simple procedure has shown itself able to promote liver regeneration. The PPVA procedure has shown itself to be safe and simple as well as to offer a promising approach to the failing liver.

Extrahepatic collaterals and liver damage in embolotherapy for ruptured hepatic artery pseudoaneurysm following hepatobiliary pancreatic surgery

To evaluate the effects of extrahepatic collaterals to the liver on liver damage and patient outcome after embolotherapy for the ruptured hepatic artery pseudoaneurysm following hepatobiliary pancreatic surgery. We reviewed 9 patients who underwent transcatheter arterial embolization (TAE) for the ruptured hepatic artery pseudoaneurysm following major hepatobiliary pancreatic surgery between June 1992 and April 2006. We paid special attention to the extrahepatic arterial collaterals to the liver which may affect post-TAE liver damage and patient outcome. The underlying diseases were all malignancies, and the surgical procedures included hepatopancreatoduodenectomy in 2 patients, hepatic resection with removal of the bile duct in 5, and pancreaticoduodenectomy in 2. A total of 11 pseudoaneurysm developed: 4 in the common hepatic artery, 4 in the proper hepatic artery, and 3 in the right hepatic artery. Successful hemostasis was accomplished with the initial TAE in all patients, except for 1. Extrahepatic arterial pathways to the liver, including the right inferior phrenic artery, the jejunal branches, and the aberrant left hepatic artery, were identified in 8 of the 9 patients after the completion of TAE. The development of collaterals depended on the extent of liver mobilization during the hepatic resection, the postoperative period, the presence or absence of an aberrant left hepatic artery, and the concomitant arterial stenosis adjacent to the pseudoaneurysm. The liver tolerated TAE without significant consequences when at least one of the collaterals from the inferior phrenic artery or the aberrant left hepatic artery was present. One patient, however, with no extrahepatic collaterals died of liver failure due to total liver necrosis 9 d after TAE. When TAE is performed on ruptured hepatic artery pseudoaneurysm, reduced collateral pathways to the liver created by the primary surgical procedure and a short postoperative interval may lead to an unfavorable outcome.

Major Hepatobiliary Surgery during Pregnancy: Safety and Timing

Hepatobiliary disease, although rare, may present during pregnancy with potential complications for mother and fetus. We present two cases of choledochal cysts and one case of a hepatic adenoma diagnosed in gravid patients. All three patients had acute events or failed medical management and were successfully treated with open resection, excision, or reconstruction during the second or third trimesters of pregnancy without requiring blood transfusions or tocolytic therapy. Although conservative treatment may be indicated in select patients due to the risk of underlying disease, we recommend surgical treatment preferably in the second trimester. With diligent intra- and postoperative management, pregnant patients can safely proceed with major hepatobiliary surgery.

Predicting postoperative morbidity by clinical assessment

The aim of this study was to determine the accuracy of prediction of the surgeon's 'gut-feeling' in estimating postoperative outcome. A prospective series of 1077 consecutive patients undergoing major hepatobiliary or gastrointestinal surgery were studied. Patients having elective (n = 827) and emergency (n = 250) procedures were included. The surgeon predicted the development of postoperative complications immediately after completion of surgery on a scale from 0 to 100 percent. These predictions were compared with the actual outcome and with predictions made using the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM). The Portsmouth predictor equation (P-POSSUM) was applied for the estimation of mortality. The observed morbidity and mortality rates were 29.5 and 3.4 percent respectively. POSSUM predicted a morbidity rate of 46.4 percent and P-POSSUM a mortality rate of 6.9 percent. The surgeon's gut-feeling was more accurate in the prediction of morbidity at 32.1 percent. On the basis of gut-feeling, surgeons overpredicted morbidity in elective surgery, but underestimated the risk of complications in the emergency setting. The (P)-POSSUM scoring system overpredicted morbidity and mortality for elective and emergency operations. The surgeon's gut-feeling is a good predictor of postoperative outcome, especially after elective surgery. (P)-POSSUM overpredicted morbidity and mortality in this series of major gastrointestinal and hepatobiliary operations.

In vivo effect of haemodilution with saline on coagulation: a randomized controlled trial

Previous studies have shown that 10-30% haemodilution with crystalloid may induce a hypercoagulable state demonstrable by using the Thrombelastograph (TEG). While most are in vitro studies, the few in vivo studies are limited by confounding surgical or 'environmental' factors. We conducted this randomized controlled study to evaluate the coagulation changes associated with in vivo haemodilution. Twenty patients undergoing major hepatobiliary surgery were randomly allocated to one of two study groups. Group H (n = 10) had 30% blood volume withdrawn over 30 min and replaced with saline. Group C (n = 10) did not have any blood withdrawn. Blood samples were taken in both groups at 10, 20 and 30 min. Native TEG, complete blood count, coagulation profile, fibrinogen, antithrombin III, protein C and thrombin-antithrombin complex concentrations were measured. Compared with Group C, Group H patients had significantly greater shortening of r-time at 30 min (-30% vs +36%), greater shortening of k-time at all time points (-36% vs +17% at 10 min; -37% vs +44% at 20 min; -45% vs +49% at 30 min), and greater widening of alpha at 30 min (+71% vs +4%). The decrease in antithrombin III and other natural procoagulants and anticoagulants closely followed that of haematocrit, with the exception of thrombin-antithrombin complex. In vivo haemodilution of up to 30% with saline can induce a hypercoagulable state. The mechanism remains unclear as disproportionate dilution of natural anticoagulants was not detected. Thrombin-antithrombin complex concentration remained stable despite haemodilution in Group H, which may suggest increased thrombin generation.

Avoiding Iatrogenic Hyperchloremic Acidosis—Call for a New Crystalloid Fluid

Rebecca Terry White Distinguished ChairDepartment of AnesthesiologyDsprough@utmb.eduProfessor and ChiefSection on Pulmonary Medicine and Critical CareThe University of Texas Medical BranchGalveston, Texas 77555-0591In Reply:—We appreciate the comments of Drummond 1and Story et al. 2Both letters address issues that clarify the report by Scheingraber et al. 3First, Drummond 1appropriately calls additional attention to the important study by his colleagues at the Royal Infirmary in Edinburgh. 4Both McFarlane and Lee 4and Scheingraber et al. 3conducted randomized clinical trials comparing 0.9% saline balanced salt solutions. The two studies differ in that McFarlane and Lee 4enrolled patients undergoing “major hepatobiliary or pancreatic surgery” averaging approximately 3.5 h in duration, whereas Scheingraber et al. 3enrolled patients undergoing “lower abdominal gynecologic surgery” averaging approximately 2.25 h. Despite the somewhat shorter duration of surgery, the gynecologic patients randomized to the saline group received a slightly greater total volume 3(71 ± 14 ml/kg during the first 120 min of infusion) than the patients receiving saline in the study by McFarlane et al. 4(14.6 ± 41 ml · kg−1· h−1during an interval of 219 ± 77 min). As a consequence, the increase in plasma chloride and the decrease in plasma bicarbonate were greater in the gynecologic patients. Together, the reports suggest that hyperchloremic acidosis is a dose-dependent consequence of saline administration. Whether this acid–base abnormality is in fact harmful remains unclear, although we 5were unable to cite any compelling evidence of adverse effects. We are skeptical that differences in outcome, if any, related to the choice of saline or balanced salt solution would justify the cost of a randomized clinical trial.However, one noteworthy characteristic of Plasmalyte 148, the balanced salt solution used by McFarlane and Lee, 4is that the sodium concentration is 140 mEq/l. Consequently, in contrast to lactated Ringer’s solution, infusion of substantial volumes does not decrease serum sodium and serum osmolality, and does not raise the same theoretical concerns about increases in brain water. 5We agree with Story et al. 2that the Stewart approach 6,7offers interesting insights into acid–base chemistry; however, we disagree that the relative merits of the Stewart approach versus the conventional Henderson-Hasselbalch approach constitute a “central issue.” Regardless of its attractive biochemical features, the Stewart approach has not yet become popular for routine clinical use, perhaps because it is less simple to quantify at the bedside and because it prompts no important differences in treatment.

Nutritional Risk Factors in Major Hepatobiliary Surgery

Preoperative nutritional assessment was performed for 32 patients undergoing surgery for malignant hepatobiliary and pancreatic disease. Weight, mid-arm circumference, total body potassium (TBK), and skin test reactivity were significantly reduced in the seven patients who died after operation (p less than .05, Student's t-test and Fisher's exact test). Analyses of major life-threatening complications indicated that those who had a complicated postoperative course (17 patients) had a significantly lower TBK (p less than .05, Fisher's exact test). Using linear discriminant analysis (SPSS computer program), correct prediction of postoperative death or survival was possible in 85% of patients if measured by TBK alone, and in 83% if weight loss and serum albumin were used. Seventy three percent were correctly classified as complicated or uncomplicated by TBK alone, but serum albumin and weight loss were not helpful in predicting patients with complications. This study shows that malnutrition and operative risk may be identified preoperatively in patients with malignant hepatobiliary and pancreatic disease. Objective improvement may be achieved by intensive nutritional support.