Postoperative Bile Leakage Research Articles

Use of a piece of free omentum to prevent bile leakage after subtotal cholecystectomy

BackgroundBile leakage after subtotal cholecystectomy (SC) is clinically serious. To prevent such leakage, we developed a new surgical technique in which a free piece of omentum is plugged into the gallbladder stump (omentum plugging technique). We evaluated whether the omentum plugging technique prevents bile leakage after subtotal cholecystectomy. MethodsProspectively collected data of patients who had undergone subtotal cholecystectomy without cystic duct closure in the Department of Surgery of Kansai Medical University during the 12 years from January 2006 to March 2018 were reviewed retrospectively. The outcomes of patients who had undergone subtotal cholecystectomy with the omentum plugging technique (omentum plugging technique group) were compared with those of patients who had undergone subtotal cholecystectomy without the omentum plugging technique (Control group). The outcomes of interest were perioperative data and postoperative complications including bile leakage, necessity for interventions for complications, and duration of hospitalization. ResultsFifty of 2,447 consecutive patients (2.0%) had undergone subtotal cholecystectomy. Of these 50 patients, 18 were treated with the omentum plugging technique (omentum plugging technique group) and 32 were treated without the omentum plugging technique (Control group). One of 18 patients in the omentum plugging technique group and 14 of 32 in the Control group developed postoperative bile leakage. One postoperative interventional treatment for complications was performed in the omentum plugging technique group and 12 in the Control group. The duration of postoperative hospitalization was less in the omentum plugging technique group. ConclusionThe omentum plugging technique appears to be an effective operative technique for preventing postoperative bile leakage in selected situations when a “difficult gallbladder” is encountered.

Clinical analysis of laparoscopic right hepatic posterior lobectomy for hepatoma(with 76 cases report)

Objective To explore the clinical value of laparoscopic right hepatic posterior lobectomy for the safety and efficacy of the treatment of right hepatic posterior lobe tumor. Methods We collected patients′ clinical data for summary review, those who underwent laparoscopic right posterior lobectomy in our hepatobiliary department from Nov. 2013 to Feb. 2017. Then, we evaluated the safety and efficacy of laparoscopic right posterior lobectomy for the treatment of right posterior lobe tumor. Results In this study, 76 patients were included and 70 patients underwent laparoscopic subtotal lobe resection. The hepatic blood flow was blocked by Pringle method with an incidence of 72.37% (55/76). The mean operative time was(266.04 ± 87.44)min.The intraoperative blood transfusion rate was 10.53% (8/76) and intraoperative blood loss was(330.21 ± 163.51)ml.There were 6 cases undergoing open surgery. Thus, the transfer rate was 7.89% (6/76). As for postoperative complications, the postoperative bile leakage rate was 2.63% (2/76). There was no perioperative death and re-operation case occurred within 30 days. After the operation, the average time for hospital stay were (7.14 ± 3.39)days. All patients were followed up and the follow-up time lasted from 6 to 36 moths. Patients checked for their condition every 3 to 6 months after leaving the hospital. Malignant tumor-free survival time was (18.38 ± 6.80) months, and there was no patient dead during the follow-up period. Conclusions In the center of rich experience of laparoscopic hepatectomy , strict indications, rational use of surgical techniques, equipment, complete laparoscopic right hepatic lobe resection for the treatment of right posterior lobectomy tumors is safe and effective, worthy of further promotion. Key words: Laparoscopy; Right hepatic posterior lobectomy; Hepatoma

Application of the cold cutting technique in transumbilical single-incision laparoscopic liver resection

Objective To study the application of the cold cutting technique in transumbilical single-incision laparoscopic liver resection (TUSI-LLR), and to evaluate its feasibility and treatment results. Methods The clinical data of 35 patients with liver lesions treated by transumbilical single-incision laparoscopic liver resection from 2013 to 2017 were retrospectively analyzed in Shengjing Hospital of China Medical University. In all these patients, the liver parenchyma was transected with the cold cutting technique. The operation time, intraoperative blood loss, postoperative complications, time to remove abdominal drain, and total hospital stay in the patients were analyzed. Results 11 of the 35 patients were male. The average age was (49.9±10.8) years. The average body weight was (63.2±11.1) kg. The diagnoses were hemangiomas in 18 patients, hepatolithiasis in 5 patients, malignant hepatocellular tumors in 5 patients, focal nodular hyperplasia in 3 patients, and others in 4 patients. There were 22 left lateral sectionectomies, 2 left hemihepatectomies, 11 wedge resections (8 in the left and 3 in the right). The operations were all successfully performed, with no conversion to conventional laparoscopic hepatectomy or open surgery. The average operation time was (112.2±51.0) minutes, and the intraoperative blood loss was (105.4±70.1) ml. No patients required intraoperative blood transfusion. The average surgery cost was (36 336.7±5 938.2) yuan. All patients recovered well, with no postoperative hemorrhage, bile leakage, or incisional wound infection. The average time periods for removal of the abdominal drain, and hospital stay were (4.5±1.2) days and (5.2±1.4) days, respectively. All the 35 patients were followed up (1~3 months), with no patients complaining of abdominal distension or abdominal pain. Conclusions The cold cutting technique in transumbi-lical single-incision laparoscopic liver resection was safe and feasible. Its benefits included the operative speed, the small amount of intraoperative blood loss and the rapid postoperative recovery of the patients. Key words: Cold cutting technique; Liver resection, laparoscopic, single incision; Stapling devices

Application of "three lines and one plane" as anatomic landmarks in laparoscopic surgery for bile duct stones.

To investigate the clinical application ofthe “three lines and one plane” concept as the anatomic landmarks during laparoscopic common bile duct exploration (LCBDE).From January 2014 to February 2017, 148 cases of LCBDE performed in the General Surgery Department of the 2nd affiliated Hospital of Anhui Medical University were recruited, and analyzed in this study. “Three lines and one plane” was applied as anatomical landmarks during LCBDE, and the perioperative clinical outcomes were analyzed.No serious operational complications occurred in all the patients in this study. Two cases (1.4%) was converted to open operation. Two other cases (1.4%) suffered post-operative bile leakage and were cured by conservative treatment. All patients recovered uneventfully.Anatomical landmarks of “three lines and one plane” is benefit in helping surgeons to build a three-dimensional (3D) anatomical construction, and avoiding the operative injury of the bile duct, and vessels.

Various approaches of laparoscopic common bile duct exploration plus primary duct closure for choledocholithiasis: A systematic review and meta-analysis

BackgroundCommon bile duct (CBD) stones may occur in up to 3%–14.7% of all patients with cholecystectomy. Various approaches of laparoscopic CBD exploration plus primary duct closure (PDC) are the most commonly used and the best methods to treat CBD stone. This systematic review was to compare the effectiveness and safety of the various approaches of laparoscopic CBD exploration plus PDC for choledocholithiasis. Data sourcesRandomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) (case-control studies or cohort studies) were searched from Cochrane library (until Issue 2, 2015), Web of Science (1980-January 2016), PubMed (1966-January 2016), and Baidu search engine. After independent quality assessment and data extraction, meta-analysis was conducted using RevMan 5.1 software. ResultsFour RCTs and 18 NRCTs were included. When compared with choledochotomy exploration (CE) plus T-tube drainage (TTD) (CE + TTD), CE plus PDC (CE + PDC) and CE + PDC with biliary drainage (BD) (CE + PDC + BD) had a lower rate of postoperative biliary peritonitis (OR = 0.22; 95% CI: 0.06, 0.88; P < 0.05; OR = 0.27; 95% CI: 0.08, 0.84; P < 0.05; respectively) where T-tubes were removed more than 3 weeks. The operative time of CE + PDC was significantly shorter (WMD = -24.82; 95% CI: −27.48, −22.16; P < 0.01) than that of CE + TTD in RCTs. Cystic duct exploration (CDE) plus PDC (CDE + PDC) has a lower rate of postoperative complications (OR = 0.39; 95% CI: 0.23, 0.67; P < 0.01) when compared with CE + PDC. Confluence part micro-incision exploration (CME) plus PDC (CME + PDC) has a lower rate of postoperative bile leakage (OR = 0.17; 95% CI: 0.04, 0.74; P < 0.05) when compared with CE + PDC. ConclusionPDC with other various approaches are better than TTD in the treatment of choledocholithiasis.

The Role of Prophylactic Endoscopic Sphincterotomy for Prevention of Postoperative Bile Leak in Hydatid Liver Disease: A Randomized Controlled Study.

Bile leak is the main cause of morbidity and mortality after surgery for hydatid liver cysts. Aim was to assess the role of prophylactic endoscopic sphincterotomy (ES) in reducing postoperative bile leak in patients undergoing partial cystectomy. Fifty-four patients with hepatic hydatid cyst met inclusion criteria, 27 were excluded or declined to participate. Twenty-six women and 28 men (mean age 44.6 ± 10.1, range: 22-61 years) were randomly assigned to either group I with ES (n = 27) or group II without ES (n = 27). Demographics and clinical, laboratory, and radiological characteristics of cysts were not statistically different between two groups. Group I had a significant decrease in bile leak rate compared with group II (11.1% versus 40.7%, P = .013), with significantly shorter duration of hospital stay (P < .0001). Biliary fistula in group I had significantly lower daily output (100 mL/day versus 350 mL/day) with gradual reduction till stoppage of leak in 3-4 days without intervention. Biliary fistula in group II had a significantly higher need for biliary intervention through postoperative endoscopic retrograde cholangiopancreatography with ES compared with biliary fistula in group I (FEP = .002), with significantly longer mean time of fistula closure (P = .011) and longer time to drain removal (P < .0001). Nonbiliary complications were comparable between two groups. Prophylactic ES provides significant reduction in postoperative bile leak rate with shorter hospital stay after partial cystectomy of hydatid cyst. Biliary fistula in patients with ES has significantly lower daily output with shorter time of drain removal and shorter time to closure than patients without ES.

DIAGNOSIS AND TREATMENT OF POSTOPERATIVE BILE LEAKAGE

Aim. Improving the immediate results of surgical treatment of liver and biliary tract diseases. Material and Methods. Treatment of 142 patients with postoperative bile leakage was analyzed. Sonography, ERCP, gastroscopy, CT and MRI were used in diagnostics. There were 62 (43.7%) men and 80 (56.3%) women. Postoperative bile leakage was caused by unrepaired biliary hypertension in 14.8% of cases, undiagnosed and unliquidated cystobiliary fistulas – in 40.1%, traumatic lesions of liver and biliary tract – in 10.6 %, clips and drainage tubes dislocation – in 12%, suture failure of cystic duct, common bile duct, biliodigestive anastomoses and duodenal stump – in 22,5%. Results. Bile leakage was treated taking into account its severity and presence of bile hypertension. Endoscopic methods, EPST, biendoscopic interventions (relaparoscopy with cystic duct re-clipping), transduodenal replacement showed high efficiency. Isolated Roux loop hepaticojejunostomy was performed in severe incurable postoperative bile leakage. Complications and deaths were absent. Conclusion. Treatment of patients with postoperative bile leakage requires an individual approach and should include conservative measures, endoscopic and surgical methods of correction.

Biliary anastomotic strictures after pancreaticoduodenectomy: an underappreciated complication

Background: The incidence of biliary anastomotic strictures (BAS) after pancreaticoduodenectomy (PD) was reported to be 2.6% in 2006. With more PD being done for benign disease and improving survival of periampullary malignancy, the contemporary incidence and outcome of BAS have not been reported. Methods: A retrospective study was performed on patients who underwent PD from 2007 to 2016 at our institution. Clinicopathological data were analyzed to identify the risk factors associated with BAS, which was defined as a radiologically proved stricture at the level of the choledocho- or hepatico-jejunostomy. Early BAS was defined as stricture occurring within 3 months after surgery. Results: 2,125 patients underwent PD. Postoperatively, 374 (19.1%) developed postoperative pancreatic fistula (POPF). 68 (3.4%) had bile leak (BL). 103 (4.9%) developed BAS. Median time to BAS was 11.3 months (IQR: 4.3–23.5). On multivariate analysis, increased risk of BAS was associated with absence of preoperative jaundice (OR 4.32, p = 0.027), benign pathology (OR 1.68, p = 0.030), POPF (OR 1.62, p = 0.040), postoperative BL (OR 4.65, p < 0.001), and adjuvant radiation (OR 21.9, p < 0.001). 19 (18.5%) patients developed early BAS, which was associated with postoperative BL (OR 57.5, p = 0.010). Of patients with BAS, all patients who received adjuvant radiation (N = 12, 11.7%) developed late-BAS. All patients were treated with percutaneous biliary procedure, median number of procedures was 6 (IQR: 4–9) and 13(12.6%) required prolonged (>1 year) drainage. Two patients (1.9%) required redo-hepaticojejunostomy and 12 (11.7%) developed cancer recurrence at biliary anastomosis. Conclusion: Given changes in practices, BAS is a more frequent complication after PD. Independent predictors include absence of jaundice, benign pathology, POPF, BL, and adjuvant radiation.

Quantintative risk assessment for post-hepatectomy liver failure: analysis of the 2015 ACS-NSQIP procedure-targeted hepatectomy database

Background: Post-hepatectomy liver failure (PHLF) is a feared complication following liver resection and a major cause of significant perioperative morbidity and mortality. The aim of this study was to analyze the quantitative risk association of perioperative factors with PHLF. Methods: Analysis of patients in the 2015 ACS NSQIP Procedure-Targeted Hepatectomy Database, who underwent hepatectomy, was done. In this database, PHLF is graded according to the International Study Group of Liver Surgery (ISGLS). Multiple regression model was performed to assess the association of perioperative factors with PHLF. Results: A total of 3,854 patients who underwent hepatectomy were analyzed. PHLF occurred in 218 patients (5.7%). Of these, 106 (48.6%) had ISGLS grade A PHLF, 64 (29.4%) grade B, and 48 (22%) grade C. Open hepatectomy was associated with 13-fold risk of PHLF compared to minimally invasive hepatectomy (p = 0.018), postoperative bile leak with a 5-fold risk of PHLF (p < 0.0001) and liver cirrhosis and parenchymal congestion with 2-fold risk of PHLF (p = 0.004 and 0.02). Increased INR and bilirubin on or after postoperative day 5 were associated with slightly increased risk of PHLF (p < 0.0001 and p < 0.001). Preoperative stenting, hepatitis B/C status, intraoperative ablation, major versus minor hepatectomy, duration of drain, and drain bilirubin level had no association with PHLF. Pringle maneuver use and hepatobiliary reconstruction were protective against PHLF. Conclusion: PHLF occurs in 5.7% of hepatectomies. The risk of developing PHLF is 13-fold after open hepatectomy compared to minimally invasive hepatectomy, 5-fold in patients with post- hepatectomy bile leak, and 2-fold in patients with liver parenchymal congestion and cirrhosis. Use of Pringle maneuver and hepatobiliary reconstruction are protective against PHLF.

Clinical efficacy of three-dimensional laparoscopic surgery in treatment of hepatic cystic echinococcosis.

Objective To investigate the clinical efficacy of three-dimensional (3D) laparoscopic surgery in treatment of hepatic cystic echinococcosis. Methods The retrospective cross-sectional study was conducted. The clinical data of 40 patients with hepatic cystic echinococcosis who underwent 3D laparoscopic surgery in the Qinghai Province People′s Hospital from March 2016 to July 2017 were collected. All the 40 patients were treated using 100 mg hydrocortisone on preventing intraoperative anaphylaxis. The experienced surgeons with proficiency in the laparoscopic technology in the same team finished surgery. Patients underwent respectively 3D laparoscopic excision of internal capsule in hepatic echinococcosis+ residual cavity treatment, external capsule resection in hepatic echinococcosis and partial hepatectomy based on their conditions. Observation indicators: (1) intraoperative situations: operation completion, surgical procedures, operation time, volume of intraoperative blood loss and blood transfusion; (2) postoperative recovery situations: time to initial anal exsufflation, time for initial fluid diet intake, time for out-of-bed activity, time of indwelling drainage-tube, wound healing, postoperative complications and duration of postoperative hospital stay; (3) follow-up: number of patients with follow-up, follow-up time, oral anti-echinococcosis medical therapy during follow-up, hepatic echinococcosis recurrence and abdominal cavity implantation metastasis. Follow-up using outpatient examination and telephone interview was performed to detect the abdominal symptoms, oral anti-echinococcosis medicine, hepatic echinococcosis recurrence and metastasis up to September 2017. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). Results (1) Intraoperative situations: all the 40 patients underwent successful laparoscopic surgery, including 17 undergoing excision of internal capsule in hepatic echinococcosis+ residual cavity treatment, 15 undergoing external capsule resection in hepatic echinococcosis and 8 undergoing partial hepatectomy. Two patients were combined with abdominal and pelvic hydatids and underwent 3D laparoscopic excision. Operation time and volume of intraoperative blood loss of 40 patients were respectively (100±28)minutes and (86±24)mL, without intraoperative blood transfusion. (2) Postoperative recovery situations: time to initial anal exsufflation and time for initial fluid diet intake in 40 patients were (2.4±1.8)hours and (1.7±0.9)days. Forty patients had out-of-bed activity on the day of surgery. Of 40 patients, abdominal drainage-tubes of 39 were placed for 2-3 days; abdominal drainage-tube of 1 with postoperative residual cavity-induced bile leakage was indwelled for 2 months and then was removed. Wound healing and duration of postoperative hospital stay in 40 patients were Class-A healing and (10.5±2.1)days. During hospitalization, 39 patients didn′t have bleeding, bile leakage, anaphylactic shock, intestinal adhesion and obstruction; 1 patient with postoperative residual cavity-induced bile leakage had indwelling drainage-tube removal at 2 months postoperatively. (3) Follow-up: all patients were followed up for 2-15 months, with a median time of 9 months. During the follow-up, 40 patients were not complicated with discomforts and received oral anti-echinococcosis medical therapy, without hepatic echinococcosis recurrence and abdominal cavity implantation metastasis. Conclusion The 3D laparoscopic surgery is safe and feasible in the treatment of hepatic cystic echinococcosis, and has an obvious advantage in the treatment of irregular hepatic cystic echinococcosis, with good short-term outcomes. Key words: Echinococcosis, hepatic; Hepatic cystic echinococcosis; Minimally invasive surgery; Laparoscopy; Three-dimensional technology

Application value of laparoscopic right-posterior lobe hepatectomy using the technique of regional blood flow occlusion

Objective To explore the application value of laparoscopic right-posterior lobe hepatectomy using the technique of regional blood flow occlusion. Methods The retrospectively cross-sectional study was conducted. The clinicopathological data of 27 patients who received laparoscopic right-posterior lobe hepatectomy in the Sir Run Run Shaw Hospital of Zhejiang University from May 2007 to June 2017 were collected. The hepatocellular carcinoma, intrahepatic bile duct stone, hepatic hemangioma, focal nodular hyperplasia, cholangiocarcinoma and metastatic hepatic carcinoma were respectively detected in 13, 4, 4, 4, 1 and 1 patients. The laparoscopic right-posterior lobe hepatectomy were performed after regional blood flow occlusion. Observation indicators: (1) intra- and post-operative recovery situations; (2) follow-up situations. Follow-up using outpatient examination and telephone interview was performed to detect the postoperative recurrence of patients with benign liver diseases and survival of patients with malignant liver tumors up to August 2017. Measurement data with skewed distribution were described as M (range). Results (1) Intra- and post-operative recovery situations: 27 patients underwent successful laparoscopic right-posterior lobe hepatectomy after regional blood flow occlusion, including 24 undergoing laparoscopic surgery and 3 undergoing conversion to open surgery due to difficult exposure under laparoscopy. Operation time, volume of intraoperative blood loss, recovery time of postoperative gastrointestinal function and time of postoperative abdominal drainage-tube removal were respectively 205 minutes (range, 125-455 minutes), 400 mL (range, 50-2 000 mL), 1 day (range, 1-3 days) and 3 days (range, 2-24 days). There was no postoperative hepatic failure, bile leakage and bleeding-induced reoperation. Of 4 patients with postoperative complications, 1 with wound infection was improved by regular dressing, 1 with deep venous thrombosis of the lower extremity was improved by anticoagulant therapy and 2 with pulmonary infection were improved by anti-infective supporting treatment. The duration of postoperative hospital stay in 27 patients was 9 days (range, 5-26 days). (2) Follow-up situations: 26 of 27 patients were followed up for 2-121 months, with a median time of 17 months, and 1 patient with benign liver disease lost to follow-up. During the follow-up, 11 patients with benign liver disease had no recurrence, the tumor-free and overall survival times of 15 patients with malignant liver tumors were respectively 13 months (range, 5-57 months) and 14 months (range, 5-57 months). Conclusion Laparoscopic right-posterior lobe hepatectomy using the technique of regional blood flow occlusion is safe and feasible, with a lower risk of liver failure and better clinical efficacies. Key words: Liver neoplasms; Carcinoma hepatocellular; Hepatolithiasis; Right-posterior lobe hepatectomy; Regional blood flow occlusion; Laparoscopy

Laparoscopic and Endoscopic Cooperative Surgery Versus Endoscopic Submucosal Dissection for the Treatment of Low-Risk Tumors of the Duodenum

BackgroundThere have been no comparative studies of endoscopic submucosal dissection (ESD) and laparoscopic and endoscopic cooperative surgery (LECS) for patients with duodenal tumors regarding surgical outcomes. The aim of this study is to compare the safety and feasibility of short-term surgical outcomes of ESD and LECS for patients with low-risk tumors of the duodenum. MethodsThis was a single-center retrospective study of 68 consecutive patients with low-risk tumors of the duodenum who received surgical treatments. ESD (n = 50) was performed between 2000 and 2013 and LECS (n = 18) was performed between 2014 and 2017. ResultsThe overall incidence of perioperative complications was significantly higher in the ESD group (28%) than in the LECS group (0%) (P = 0.014). In the ESD group, eight patients with intraoperative perforation of duodenum (16%) were repaired with metal clips. Postoperative duodenal hemorrhage occurred in three patients (6%). Postoperative duodenal stricture requiring endoscopically guided balloon dilation was observed in two patients (4%). Postoperative bile leakage was found in one patient (2%). The size of resected lesion was significantly larger in the LECS group (26.5 mm) than in the ESD group (14.5 mm) (P = 0.003). In LECS group, all 18 patients underwent curative resection; however, the curative resection rate was 52% in ESD group (P = 0.001). ConclusionLECS for patients with low-risk tumors of the duodenum is a safe, feasible, and ideal alternative to ESD with regard to short-term surgical outcomes. Trial RegistrationUMIN000021200 (http://www.umin.ac.jp/ctr/)

Postoperative bile leakage and surgical site infection after hepatic resection

Postoperative bile leakage and surgical site infection after hepatic resection

The standardisation of minimally invasive methods approaches in treatment of post-laparoscopic cholecystectomy bile leakage

The paper analyses the results of surgical treatment of 10243 patients with cholelithiasis who underwent laparoscopic cholecystectomy. In the early postoperative period 60 patients (0.59%) had bile leakage. Developed surgical technique based on ultrasound data and endoscopic retrograde cholangiopancreatography can improve the results of treatment and avoid septic complications and lethal outcomes. Conservative treatment, minimally invasive endoscopic techniques, ultrasound guided puncture methods and relaparoscopy were effective in 52 patients (86,7%). Postoperative bile leakage is currently one of the most frequent complications of LCE, routine drainage of the subhepatic space facilitates early diagnosis of postoperative complications. When choleo-excretion is more than 200 ml per day, endoscopic retrograde cholangiography is necessary to diagnose damage to the main bile ducts, while confirming the injury of the hepaticocholedochus, a reconstructive surgery with laparotomy is indicated. Drainage bile bleeding, accompanied by symptoms of biliary peritonitis or a significant accumulation of bile in the abdominal cavity in the absence of an injury to the hepaticocholedochus, requires a relaparoscopy for diagnostic and therapeutic purposes. Standardization of the complex application of relaparoscopy, transduodenal endoscopic interventions and puncture techniques can significantly reduce the number of laparotomic operations to correct the complications that have arisen.

Endoscopic retrograde cholangiopancreatography results and reliability in experienced hands

Endoscopic retrograde cholangiopancreatography (ERCP) is an imaging modality that visualizes biliary tract and pancreatic ductus after giving contrast material by cannulation of ampulla vateri via a duodenoscope. It has been used in the diagnosis and treatment of pancreatic ductus and biliary tract. This study included 204 patients. There was stone formation at ductus choledochus in 147 (72.06%), malignant biliary stricture in 28 (13.73%), benign biliary stricture in 8 (3.92%), periampullary tumor in 4 (1.96%), hydatid cyst communicating with ductus choledochus in 2 (0.98%), fasciola hepatica in 1 (0.49%), sclerosing cholangitis in 4 (1.96%), sphincter of Oddi dysfunction in 5 (2.45%) and postoperative bile leakage in 3 (1.47%) of the patients. The procedure couldnÂ’t be performed in 2(0.98%) patients due to anatomic difficulties. Stone retrieval with basket and/or balloon was performed in 115 (56.37%) patients while plastic stents was inserted to ductus choledochus in 87 (47.64%) and in pancreatic ductus in 5 (2.45%) patients. Mechanical lithotripsy was performed in 6 (2.94%) patients. Following ERCP, pancreatitis was developed in 3 (1.47%) patients, whereas sepsis in 2(0.98%) and bleeding in another 2 (0.98%) patients. ERCP remains to be an effective method in the diagnosis and treatment of biliary tract and pancreatic ductus in experienced hands.

Impact of Ultrasonic Scalpels for Liver Parenchymal Transection on Postoperative Bleeding and Bile Leakage.

Novel techniques for liver parenchymal transection have emerged and they are available to the hepatobiliary surgeon. The aim of our study was to compare two types of ultrasonic scalpels (Lotus and Harmonic) and examine how they perform either alone or in combination with the SonaStar ultrasonic surgical aspiration system regarding postoperative bleeding and bile leakage. Our prospectively maintained database of patients who underwent liver resections in our Department was reviewed. One hundred and two patients with solid liver lesions underwent liver resection by a senior hepatobiliary surgeon in our department during a period of 51 months. They were divided into four groups according to the devices that were used for liver parenchymal transection. Patients were divided into the following groups: group 1: Lotus, 32 patients (31.4%); group 2: Lotus+SonaStar, 27 patients (26.5%); group 3: Harmonic, 27 patients (26.5%); group 4: Harmonic+SonaStar, 16 patients (15.7%). There were 5 cases of postoperative bleeding and 9 cases of postoperative bile leakage. No significant difference was found concerning postoperative bleeding (group 1: 2/32; 6.3%, group 2: 2/27; 7.4%, group 3: 0/27; 0%, group 4: 1/16; 6.3%) (p=0.577). Furthermore, no actual difference was detected in terms of postoperative bile leakage (group 1: 2/32; 6.3%, group 2: 3/27; 11.1%, group 3: 3/27; 11.1%, group 4: 1/16; 6.3%) (p=0.866). Both Lotus and Harmonic ultrasonic scalpels provide adequate and similar results concerning postoperative hemorrhage and cholorrhea.

Does preoperative magnetic resonant cholangiopancreatography (MRCP), improve the safety of laparoscopic cholecystectomy?

BackgroundMagnetic resonance cholangiopancreatography (MRCP) is a non-invasive imaging test with excellent overall sensitivity and specificity for demonstrating the level and the presence of a biliary obstruction. MRCP has emerged as an accurate, diagnostic modality for investigating the biliary and pancreatic duct. In some cases, it has been recommended that preoperative MRCP is a good choice for the detection of CBD stones. AimThe aim of the study is to assess the value of preoperative MRCP on the safety of laparoscopic cholecystectomy. MethodsThe randomized study was carried out on 100 patients aged 16–65 years, admitted in Baghdad Teaching Hospital between 2013 and 2015. Laparoscopic cholecystectomy was performed for them. 45 patients had preoperative MRCP followed by conventional laparoscopic cholecystectomy, while 55 patients underwent only laparoscopic cholecystectomy. The findings of the two groups were compared. ResultsIn the first group: pre-operative MRCP screening exposed clinically silent CBD stones in 2 patients (4.44%), while one patient (2.22%) had accessory cystic duct and another one had an abnormal insertion of cystic duct (2.22%). In the second group, 4 patients had postoperative complications (P < 0.05): residual stones, postoperative bile leak, jaundice and pancreatitis.

Liver hydatid cyst with cystobiliary communication: Laparoscopic surgery remains an effective option.

Introduction:Most centres offer laparoscopic treatment for liver hydatid cyst (LHC). There have been concerns about the management of intra-peritoneal spillage, bleeding, and cystobiliary communication (CBC) during laparoscopic surgery for LHC. CBC can exist in 13%–37% of cases of LHC. No randomised studies have compared open versus laparoscopic approach for the treatment of LHC. We specifically analysed the outcomes of laparoscopic treatment of LHC with special reference to associated biliary complications.Patients and Methods:We analysed our prospectively collected data of patients undergoing laparoscopic treatment of LHC from 2009 to 2016. Patients undergoing open surgery or interventional radiology procedures were not included. Data analysed included demographic profile, investigational parameters, intra-operative findings and postoperative results with special reference to biliary complications and presence/management of CBC.Results:A total of 41 patients underwent laparoscopic treatment of LHC. History of jaundice was present in 5 (12.2%) patients. CBC was documented in 16 (39.02%) patients. In 11 patients, CBC was detected intra-operatively as visible communication, which was suture ligated or clipped. Five patients had occult CBC, detected as bile leak in the post-operative period. The leak resolved spontaneously in 7 patients and with biliary stenting in 2 patients. Only one patient had a persistent biliary leak. Postoperative bile leak was more common in patients with raised alkaline phosphatase. No statistically significant association was seen with size or location of the cyst, number of cysts and World Health Organisation classification.Conclusion:Laparoscopic treatment of LHC with associated CBC provides acceptable results.

Non-Surgical Management of Bile Leakage After Hepatectomy: A Single-Center Study

Bile leakage after hepatectomy is a common complication. The purpose of the present study was to retrospectively evaluate the usefulness of non-surgical management of bile leakage after hepatectomy, using 12-year data from a single center study. Data from 15 patients (13 men, two women; mean age 67.1 ± 7.0 years) who had undergone non-surgical management for bile leakage between January 2005 and November 2017 were retrospectively reviewed. We categorized bile leakage as central (n = 5) or peripheral (n = 10) leakage based on communication with the biliary tree. Percutaneous bile leakage drainage and/or endoscopic naso-biliary drainage (ENBD) (n = 2) or the rendezvous technique (n = 3) was successfully performed in five central-type cases, while all peripheral-type cases were treated with drainage alone; only one case required additional ethanol ablation. Bacterial bile cultures were positive in 11 cases and negative in four cases. The drainage catheters were removed after complete resolution in 13 cases (86.7%), while two patients with cases of peripheral-type leakage died due to cancer progression while the drain was in place. No case needed conversion to reoperation. The mean duration of drainage therapy in all cases was 210.1 ± 163.0 days (range 17-531 days), with 316.8 ± 180.8 days in the central type and 156.7 ± 131.5 days in the peripheral type; this duration was not significantly different (P = 0.129). Non-surgical treatment is a minimally invasive and effective management strategy for postoperative bile leakage and the modality used depends on the type of bile leakage encountered.

Comparison of the effect of primary suture and T tube drainage of laparoscopic common bile duct exploration in the treatment of patients with choledocholithiasis

Objective To compare the effect of primary suture and T tube drainage of laparoscopic common bile duct exploration(LCBDE) in the treatment of patients with choledocholithiasis. Methods A total of 57 patients with calculus of extrahepatic bile duct were selected and they were randomly divided into observation group(n=25, treated by LCBDE) and control group(n=32, treated by T tube drainage). The operation time, postoperative recovery time of gastrointestinal tract, abdominal drainage time, postoperative hospital stay, hospitalization expenses and postoperative complications were recorded and compared between the two groups. Results All the patients were successfully completed surgery, and no patients had open surgery.The recovery time and postoperative hospital stay of the observation group were (1.7±0.5)d, (5.3±1.6)d, respectively, which were significantly shorter than (2.1±0.3)d, (9.2±1.9)d of the control group(t=11.73, 6.27, all P 0.05). There were 4 cases of postoperative bile leakage and 1 case of common bile duct residual stones in the observation group, and the incidence rate of complications was 20.00%.There were 2 cases of bile leakage, 3 cases of common bile duct residual stones and 2 cases of biliary peritonitis in the control group, and the incidence rate of complications was 21.87%.There was no statistically significant difference in the incidence rate of complications between the two groups (χ2=0.15, P>0.05). All the patients were followed up for 1 to 2 years, the recurrence rate of stones in the observation group was 12.00%, which was similar to 15.60% in the control group(χ2=0.36, P>0.05). Conclusion Primary suture of laparoscopic common bile duct exploration has the advantages such as less trauma, less pain, faster recovery and shorter hospital stay in the treatment of patients with choledocholithiasis, which is worthy of clinical application and popularization. Key words: Laparoscopy; Choledocholithiasis; Suture techniques; Drainage