Preoperative Cholangitis Research Articles

Intraoperative Bacterial Translocation Detected by Bacterium-Specific Ribosomal RNA-Targeted Reverse-Transcriptase Polymerase Chain Reaction for the Mesenteric Lymph Node Strongly Predicts Postoperative Infectious Complications After Major Hepatectomy for Biliary Malignancies

There is little evidence indicating a causal linkage between bacterial translocation and postoperative infectious complication (POIC) in human studies. To investigate the correlation between the occurrence of bacterial translocation in the mesenteric lymph node (MLN) and POIC with a sensitive quantitative method using bacterium-specific ribosomal RNA (rRNA)-targeted reverse transcriptase-polymerase chain reaction (RT-qPCR). Patients who underwent major hepatectomy for biliary malignancies involving hepatic hilus were included in this study (n = 65). Mesenteric lymph nodes were harvested from the jejunal mesentery 2 times during the operation (MLN-1 harvested at laparotomy and MLN-2 harvested after tumor resection). Microorganisms were detected by a bacterium-specific rRNA-targeted RT-qPCR method. Perioperative factors and POIC were recorded prospectively. Of 65 patients, 51 completed the study. Microorganisms were detected in MLN-1 and MLN-2 in 15 (29.4%) and 19 (37.3%) patients, respectively. The detection of microorganisms in MLN-1 was significantly correlated with the incidence of preoperative cholangitis (P = 0.04), whereas the detection of microorganisms in MLN-2 was significantly correlated with the incidence of POIC (P = 0.002). In multivariate analysis, a positive result for detection of microorganisms in MLN-2 was one of the independent predictive factors of POIC (odds ratio = 26.1). Intraoperative analysis of MLNs (especially MLN-2) by rRNA-targeted RT-qPCR can strongly predict the occurrence of POIC after hepatectomy for biliary malignancy. This method is more sensitive and faster at detection of microorganisms than the conventional culture method. Therefore, we can obtain the information of bacterial translocation immediately after the surgery and can select the group of patients with high risk for POIC.

Surgical treatment of hilar cholangiocarcinoma in the new era: the Asan experience

Both curative resection and minimized in-hospital mortality offer the only chance of long-term survival in patients with hilar cholangiocarcinoma. The reported resectability rates for hilar cholangiocarcinoma have increased by virtue of combined major hepatectomy, but this procedure is technically demanding and still associated with a significant morbidity and mortality that must be carefully balanced against the chances of long-term survival. Between January 2001 and December 2008, 350 patients with hilar cholangiocarcinoma underwent exploration for the purpose of potentially curative resection, of whom 302 (86.3%) were resected in the Department of Hepato-Biliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine. Combined hepatectomy was carried out in 268 (88.7%) of 302 resected patients. Major hemihepatectomy and parenchyma-preserving hepatectomy were performed in 257 and 11 patients, respectively. Portal vein resection was associated in 40 (14.9%) of 268 hepatectomized patients. To control preoperative cholangitis and reduce risk of postoperative hepatic failure, biliary decompression through endoscopic and/or percutaneous transhepatic drainage and portal vein embolization were preoperatively applied in 329 (94.0%) of 350 explored patients and in 91 (54.2%) of 168 extended hepatectomized patients (154 right hemihepatectomy, 9 right trisectionectomy, 5 left trisectionectomy), respectively. Liver transplantation was not performed as primary treatment for hilar cholangiocarcinoma. There were 5 cases (1.7%) of in-hospital death after resection and 1 postoperative liver failure that was successfully treated with liver transplantation. Major complications were encountered in 23 patients (7.0%), and the overall morbidity rate was 43%. In 302 resections, 214 (70.9%) were curative resections (R0) and 88 (29.1%) were palliative resections (R1). The overall 1-, 3- and 5-year survival rates after resection, including in-hospital deaths, were 84.6, 50.7 and 47.3% in the R0 group and 69.9, 33.3 and 7.5% in the R1 group, respectively. The 5-year survival rate of extended hemihepatectomy of 36.4% was better than that of parenchyma-preserving hepatectomy at 10.5%. Two significant predictive factors adversely affecting survival after resection were lymph node metastasis and incurability of surgery (P < 0.001). Two patients with vascular involvement who underwent concomitant hepatic artery and portal vein reconstruction are alive after more than 3 years. Preoperative biliary decompression and portal vein embolization enabled us to reduce in-hospital deaths associated with extended hepatectomy for hilar cholangiocarcinoma. Major hemihepatectomy offers an increased survival because of the higher possibility of curative resection than bile duct resection alone and parenchyma-preserving hepatectomy, but it still carries a certain mortality. Less extensive procedures can be conducted safely and are beneficial for aged patients in poor condition with a less advanced tumor stage if tumor-free resectional margins are obtained.

Preoperative cholangitis independently increases in-hospital mortality after combined major hepatic and bile duct resection for hilar cholangiocarcinoma

This study evaluated the impact of ductal bile bacteria (bactibilia or cholangitis) on the development of surgical site infection (SSI) or in-hospital mortality after resection for hilar cholangiocarcinoma. A retrospective analysis was conducted on 81 patients who underwent a combined major hepatic (hemihepatectomy or more extensive hepatectomy) and bile duct resection for hilar cholangiocarcinoma. Ductal bile was submitted for bacterial culture before or during the operation. The incidence of SSI was higher in patients with preoperative bactibilia (83%) than in patients without (52%; P = 0.008). Preoperative bactibilia was an independent variable associated with SSI (relative risk 9.003; P = 0.002). The incidence of in-hospital mortality was higher in patients with preoperative cholangitis (33%) than in patients without (6%; P = 0.009). Preoperative cholangitis was the only independent variable associated with in-hospital mortality (relative risk 9.115; P = 0.006). Preoperative cholangitis independently increases in-hospital mortality after combined major hepatic and bile duct resection for hilar cholangiocarcinoma, whereas preoperative bactibilia independently increases SSI.

One Hundred Two Consecutive Hepatobiliary Resections for Perihilar Cholangiocarcinoma With Zero Mortality

To analyze the short-term surgical outcome of hepatobiliary resections for perihilar cholangiocarcinoma in the last 5 years. Hepatobiliary resection for perihilar cholangiocarcinoma remains a technically demanding procedure, calling for a high level of expertise in biliary and hepatic surgery, and is still associated with significant morbidity or mortality. Between 2000 and 2004, we surgically treated 102 consecutive patients with perihilar cholangiocarcinoma with a management strategy consisting of preoperative biliary drainage, portal vein embolization (for right-sided and extended left-sided resections), and major hepatobiliary resection. The data on all of the patients were analyzed retrospectively to identify the factors that might significantly affect the postoperative mortality and morbidity. There were no cases of in-hospital mortality or postoperative liver failure. Major complications were encountered in 7 patients (6.9%), and the overall morbidity rate was 50%. Reoperation was required in 2 patients (2%). The overall median length of postoperative hospital stay was 26 days (range, 13-119 days). Univariate analysis in relation to the postoperative morbidity showed significant differences in the preoperative occurrence of segmental cholangitis or cholecystitis (P = 0.015), the severity of postoperative hyperbilirubinemia (P < 0.001), and the total amount of fresh frozen plasma administered (P = 0.002). Multivariate analysis revealed a single independent significant predictive factor for postoperative morbidity, namely, preoperative cholangitis or cholecystitis (odds ratio, 9.08; 95% confidence interval, 1.05-78.56, P = 0.045). Our experience indicates that hepatobiliary resections for perihilar cholangiocarcinoma can be conducted safely, without a single case of postoperative liver failure or mortality. Occurrence of preoperative cholangitis or cholecystitis is a significant indicator for morbidity of major hepatobiliary resection.

Factors influencing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy.

Delayed gastric emptying (DGE) is the most frequent postoperative complication after pylorus-preserving pancreatoduodenectomy (PPPD). This study was undertaken to determine which factors influence the development of DGE after PPPD. We studied 150 consecutive patients who underwent PPPD performed by one surgeon between 1996 and 2000. The variables analyzed were age, gender, diagnosis, laboratory data, operative time, transfusion, preoperative cholangitis, and complications. The operative factors included were route of the afferent jejunal limb (retromesenteric versus antemesenteric), type of pancreatoenteric anastomosis, and preservation of the right gastric artery. DGE was defined as nasogastric drainage for more than 10 days or delay of regular diet until 14 days postoperatively. Univariate analysis showed preoperative cholangitis, intraabdominal complication, and the jejunal reconstruction method were significantly associated with DGE. Preservation of the right gastric artery was not associated with gastric emptying ability. Multivariate analysis by logistic regression showed that DGE was significantly more frequent among patients with preoperative cholangitis (15 of 36 [41.7%] versus 19 of 114 [16.7%], p=0.0031), postoperative intraabdominal complications (15 of 36 [41.7%] versus 10 of 114 [8.8%], p = 0.0001), and in the retromesenteric group (33 of 104 [31.7%] versus 3 of 46 [6.5%], p = 0.0174). Preoperative cholangitis and postoperative leakage problems affect gastric emptying after PPPD during the early postoperative period. The retromesenteric route is not recommended for pancreato- and biliary-enteric anastomosis. We speculate that retromesenteric passage of afferent jejunum can cause venous congestion and bowel edema, which can in turn retard the recovery of jejunal peristalsis at the duodenojejunostomy site resulting in disturbance from food passage.

Cholangitis associated with cystic dilatation of the intrahepatic bile ducts after antireflux valve construction in biliary atresia.

An intussusception-type antireflux valve (ARV) has been introduced to prevent postoperative ascending cholangitis in the management of biliary atresia (BA). We investigated the characteristics of cholangitis in the management of BA using the ARV in 38 patients who had undergone an operation at our institution; 29 underwent ARV construction at the same time as portenterostomy (PEO) or hepaticojejunostomy. One patient underwent ARV construction for refractory cholangitis with cystic dilatation of the intrahepatic bile ducts (CDIB) long after the PEO. Five of 29 patients who had ARV construction developed CDIB complicated by severe, refractory cholangitis. One or two episodes of mild cholangitis were observed in 5 (20.8%) of 24 patients who did not show CDIB. An ARV created for postoperative recurrent cholangitis associated with CDIB was ineffective. Preoperative cholangitis associated with a type I choledochal cyst and CDIB was observed in 1 patient. In conclusion, the ARV was effective in preventing refractory cholangitis without CDIB, but ineffective in preventing cholangitis with CDIB. Our findings suggest that CDIB resulting from the ongoing process of BA could be a potential target of bacterial infection through other routes than bilioenteric reflux.

Extended hepatic resection: a 6-year retrospective study of risk factors for perioperative mortality

Background: Extended hepatic resection (more than four liver segments) is a major operative procedure that is associated with significant risk. The purpose of this study was to assess the impact of perioperative variables on in-hospital mortality after extended hepatectomy. Study Design: Consecutive patients who underwent extended hepatic resection were studied. The prognostic value of 29 perioperative variables was evaluated using in-hospital mortality as the endpoint. For each variable, the odds ratio (95% confidence interval) for in-hospital mortality was calculated. Those variables with a lower confidence limit > 1 were considered important risk factors. The population was stratified into categories of patients having the same number of risk factors, and mortality was estimated for each group. These data were used to develop a risk assessment algorithm. Results: There were 14 deaths (6%) in 226 patients. Three preoperative variables (cholangitis, creatinine > 1.3 mg/dL, and total bilirubin > 6 mg/dL) and two operative variables (blood loss > 3 L and vena caval resection) appear to be important factors for in-hospital mortality. The mortality associated with the presence of any two of the five factors was 100% (5 of 5), and the mortality associated with the absence of these factors was 3% (6 of 191). Conclusions: Perioperative evaluation of patients undergoing extended hepatic resection should include the quantitation of mortality risk factors. The combination of any two factors among preoperative cholangitis, elevated serum creatinine, elevated serum bilirubin, high operative blood loss, and vena cava resection may carry a high mortality risk. These results require prospective validation.

Association of preoperative biliary stenting with increased postoperative infectious complications in proximal cholangiocarcinoma.

The indications for preoperative biliary stenting in patients with obstructive jaundice are controversial. We evaluated the effect of preoperative biliary stenting on bacterobilia and infectious complications following surgical treatment of proximal cholangiocarcinoma. A retrospective review was performed of all patients undergoing surgical treatment of proximal cholangiocarcinoma. A metropolitan cancer surgery service. Seventy-one patients underwent palliative biliary bypass or curative resection of proximal cholangiocarcinoma from March 1, 1991, to April 1, 1997, and were entered into a prospective database. Forty-one patients underwent preoperative biliary intubation and stent placement. We analyzed patient, nutritional, laboratory, and operating room factors. Statistical evaluation was performed using Student t test and chi2 analysis. Data were recorded for a history of cholangitis, operative time, amount of blood loss, incidence of intraoperative bacterobilia, proportion of patients with postoperative infectious and noninfectious complications, and length of hospital stay. All patients (n = 14) with a history of preoperative cholangitis had been subjected to previous endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic biliary drainage. Groups were equivalent for risk for comorbidity, proportion undergoing curative vs palliative procedures, time spent in the operating room, and amount of blood loss. Patients with stents had a significantly lower bilirubin level (P = .005). Patients with stents had a significantly increased risk for bacterobilia (P = .001) and infectious complications (P = .03). Bacterobilia was present in 11 (100%) of 11 patients undergoing endoscopic stenting and in 15 (65%) of 23 patients undergoing percutaneous stenting. There was no increased risk for noninfectious complications, length of hospital stay, or mortality in patients with stents. In 10 (59%) of 17 patients with postoperative infectious complications and positive findings of intraoperative bile culture, the organism was synonymous. Preoperative biliary stenting in proximal cholangiocarcinoma increases the incidence of contaminated bile and postoperative infectious complications. Endoscopic stents frequently do not relieve jaundice in high biliary obstruction and are rarely indicated, especially in light of their high contamination rate.

Preoperative intrahepatic segmental cholangitis in patients with advanced carcinoma involving the hepatic hilus

Major hepatic resection for biliary tract carcinoma continues to be a risky operation. In this study we examined the influence of preoperative intrahepatic segmental cholangitis on posthepatectomy mortality. We analyzed retrospectively the clinical features of 118 patients who underwent liver resection including more than two segments for biliary tract carcinoma involving the hepatic hilus. Intrahepatic segmental cholangitis was encountered before operation in 22 cases. The morbidity and mortality rates for these patients were significantly higher than those of patients without preoperative cholangitis. Selective percutaneous transhepatic biliary drainage was performed before operation in 11 patients for segmental cholangitis. The morbidity rate of patients after hepatectomy was significantly lower than that of patients treated without percutaneous transhepatic biliary drainage. The presence of preoperative intrahepatic segmental cholangitis is a major prognostic factor in the outcome of major hepatic resection for biliary carcinoma. Selective percutaneous transhepatic biliary drainage for preoperative intrahepatic segmental cholangitis plays an important role in reducing complications after major hepatic resection.

Successful management of preoperative cholangitis by percutaneous transhepatic biliary drainage: Case report of advanced gallbladder carcinoma with severe cholangitis

A case of advanced gallbladder carcinoma complicated with preoperative severe cholangitis is reported. The cholangitis was completely controlled after management employing percutaneous transhepatic biliary drainage (PTBD), and it was then possible to perform curative resection of the gallbladder carcinoma. Malignancy at the hepatic hilus sometimes causes acute obstructive cholangitis, followed by severe liver dysfunction, making major hepatic resection impossible. PTBD is quite useful for improving such a pathological condition.