Prevent Bile Leakage Research Articles

Standardization of a goal-oriented approach to acute cholecystitis: easy-to-follow steps for performing subtotal cholecystectomy.

A critical view of safety (CVS) is important to ensure safe laparoscopic cholecystectomy. When the CVS is not possible, subtotal cholecystectomy is performed. While considering subtotal cholecystectomy, surgeons are often concerned about preventing bile leakage from the cystic ducts. The two main types of subtotal cholecystectomy for acute cholecystitis are fenestrating and reconstituting. Previously, there were no selection criteria for these two; therefore, open conversion was performed. This study aimed to evaluate our goal-oriented approach to choose fenestrating or reconstituting subtotal cholecystectomy for acute cholecystitis. We introduced our goal-oriented approach in April 2019. Before introducing this approach, laparoscopic cholecystectomy for acute cholecystitis was performed without criteria for subtotal cholecystectomy. After our approach was introduced, laparoscopic cholecystectomy for acute cholecystitis was performed according to the subtotal cholecystectomy criteria. We retrospectively reviewed the medical records of patients who underwent laparoscopic cholecystectomy for acute cholecystitis between 2015 and 2021. Laparoscopic cholecystectomy for acute cholecystitis was performed by surgeons regardless of whether they were novices or veterans. The period from April 2015 to March 2019 was before the introduction (BI) of our approach, the period from April 2019 to December 2021 was after the introduction (AI) of our approach. There were 177 and 186 patients with acute cholecystitis during the BI and AI periods, respectively. There were no significant differences between groups in terms of preoperative characteristics, operative time, and blood loss. No difference in the laparoscopic subtotal cholecystectomy rate between groups (10.2% [BI] vs. 13.9% [AI]; p = 0.266) was obserbed. The open conversion rate during the BI period was significantly higher than that during the AI period (7.4% vs. 1.6%; p = 0.015). Our goal-oriented approach is feasible, safe, and easy for many surgeons to understand.

Prospective clinical trial of EUS–guided choledochoduodenostomy without fistula dilation for malignant distal biliary obstruction

ABSTRACT Background and Objectives During EUS–guided choledochoduodenostomy (EUS-CDS), fistula dilation before stent insertion is associated with adverse events (AEs), such as bile leakage and peritonitis. We hypothesized that EUS-CDS without fistula dilation using a novel self-expandable metal stent (SEMS) with a thin delivery system could overcome this problem, and we conducted this study to evaluate its feasibility and safety. Methods This was an open-label, single-arm, phase II study at a single institution. We planned EUS-CDS without fistula dilation using a fully covered SEMS with a 5.9-Fr delivery system for unresectable malignant distal biliary obstruction. The primary outcome was overall technical success. Secondary outcomes were technical success without fistula dilation, procedure time, functional success, time to recurrent biliary obstruction, and AEs. The planned sample size was 25 patients. Results In total, 24 patients were included in this study. In 21 patients, EUS-CDS was performed as primary drainage. The overall technical success rate was 100% (24 of 24 patients). The technical success rate without fistula dilation was 96% (23 of 24). The median procedure time was 16 min (range, 10–66 min). The functional success rate was 96% (23 of 24). The median time to recurrent biliary obstruction was 148 days (95% confidence interval, 29–266 days). There were no procedure-related AEs. Furthermore, computed tomography immediately after the procedure showed no leakage of contrast medium into the abdominal cavity in any patient. Conclusions EUS–guided choledochoduodenostomy without fistula dilation using a fully covered SEMS with a 5.9-Fr delivery system is feasible with a high probability and can be achieved quickly while effectively preventing bile leakage and peritonitis.

Protocol of a randomised controlled phase II clinical trial investigating PREoperative endoscopic injection of BOTulinum toxin into the sphincter of Oddi to reduce bile leakage after hepatic resection: the PREBOT-II trial

IntroductionBile leakage represents a major cause of morbidity following hepatic resection. Although most patients can be managed non-operatively, this complication requires diagnostics and therapeutic interventions. Preoperative endoscopic injection of botulinum...

Short-term efficacy of cholecystectomy plus bile duct T-tube drainage or choledochojejunostomy in the treatment of gallbladder cancer and its effects on median survival time and postoperative complications.

To explore the short-term efficacy of cholecystectomy plus bile duct T-tube drainage or choledochojejunostomy (CJ) in the treatment of gallbladder cancer (GC) and its effects on the median survival time and postoperative complications. The clinical data of 121 patients who underwent laparoscopic cholecystectomy (LC) in department of hepatobiliary surgery of the hospital from January 2018 to December 2018 were retrospectively analyzed. According to the adjuvant treatment methods, the patients were divided into 2 groups: the control group (n = 61, LC + bile duct T-tube drainage) and experimental group (n = 60, LC + CJ). The perioperative indicators, short-term efficacy, median survival time, postoperative complications and immune stress response were compared between the 2 groups of patients before and after propensity score matching. The surgical time, postoperative anal first exhaust time, and intraoperative blood loss in the experimental group were no different from those in the control group (P > .05), but the hospital stay was shorter than that in the control group (P < .05). There was no difference in the effective rate of treatment and median survival time between the 2 groups (P > .05). The total incidence rate of complications in the experimental group at 14 days after surgery was lower than that in the control group (P < .05). Day 3 after surgery, the levels of immunoglobulin M (IgM) and immunoglobulin G (IgG) of the experimental group were higher than those of the control group (P < .05), while the level of C-reactive protein (CRP) was lower than that of the control group (P < .05). Compared with bile duct T-tube drainage, LC + CJ in the treatment of GC can better shorten the postoperative hospital stay and reduce the postoperative complications and immune stress response, but and the median survival time of the 2 is similar, which can be promoted in clinical practice.

Endoscopic ultrasound-guided rendezvous technique in a transduodenal long endoscopic position using a 22 G needle combined with a novel 0.018-inch guidewire.

The endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a salvage technique for failed biliary cannulation with benign disorders, but its success rate is not high [1] [2] [3]. The approach in a transduodenal, long endoscopic position (TDL) is preferred because it provides easier access to the bile duct, even if the bile duct is not dilated, as it stabilizes the scope position [4]. However, the TDL method, with a combination of a 19 G needle and 0.025-inch guidewire, directs the puncture needle toward the hepatic hilum because the range of motion of the scope and the needle is limited, making guidewire advance to the papilla challenging. Recently, a novel 0.018-inch guidewire (Fielder 18; Olympus, Tokyo, Japan) has been developed, which is similar to a 0.025-inch guidewire with good visibility, maneuverability, and stiffness ([Fig. 1]). Compared with the 19 G needle with 0.025-inch guidewire, a 22 G needle with the 0.018-inch guidewire has a more extensive range of motion for puncture, and the scope can be bent more acutely ([Fig. 2], [Fig. 3]). Therefore, the tip of the puncture needle can be directed toward the papilla, and the excellent maneuverability of this guidewire allows easier advance into the duodenum ([Fig. 4]). The 22 G needle may prevent bile leakage during the procedure due to its smaller diameter.

Incidence of bactibilia and related factors in patients who undergo cholecystectomy.

In general, bile is normally sterile. However, there are reports bactibilia may occur in certain instances, though the causal factors are unclear. We analyzed possible preoperative predictors of bactibilia upon cholecystectomy. Bile samples were collected during cholecystectomies from November 2018 to November 2019. A total of 428 open or laparoscopic cholecystectomies were performed. Preoperative, intraoperative, and postoperative variables were compared between the culture-positive and culture-negative groups. One hundred fifty-seven patients (36.7%) were culture-positive. Gram-negative bacteria (95 [61.0%]) were more common. Escherichia coli (38 [40.0%]) and Enterobacter (22 [23.2%]) were the most common species. In univariate analysis, age of ≥70 years (P < 0.001), male sex (P < 0.001), high American Society of Anesthesiologists physical status grades (P = 0.001), diabetes mellitus (P = 0.002), jaundice (P = 0.007), high Tokyo Guideline grades (P = 0.008), percutaneous transhepatic gallbladder drainage (PTGBD; P < 0.001), endoscopic retrograde cholangiopancreatography (ERCP; P < 0.001) were identified as a risk factors for bactibilia. In multivariate analysis, age of ≥70 years (hazard ratio [HR], 2.874; 95% confidence interval [CI], 1.769-4.670; P = 0.001), ERCP (HR, 9.001; 95% CI, 4.833-16.75; P < 0.001), and PTGBD (HR, 2.866; 95% CI, 1.440-4.901; P = 0.002) were independent risk factors for bactibilia. Among patients who underwent cholecystectomy, those who were elderly, symptomatic, and underwent preoperative drainage were more likely to have bactibilia. In such cases, surgeons should take care to prevent bile leakage during surgery and consider administering appropriate antibiotics.

EUS-guided drainage of the gallbladder using a novel 0.018-inch guidewire for preventing bile leakage (with video).

EUS-guided drainage of the gallbladder using a novel 0.018-inch guidewire for preventing bile leakage (with video).

Efficacy of Cystic Duct Tube in Preventing Bile Leakage after Hepatectomy

Efficacy of Cystic Duct Tube in Preventing Bile Leakage after Hepatectomy

Endoscopic ultrasound-guided covered metal stent deployment through endoscopic tapered sheath preventing bile leakage.

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Advances in indocyanine green fluorescence imaging during hepatectomy

While surgical operation is the preferred treatment for liver malignancies,the postoperative recurrence rate remains high. In the early 21st century,Japanese scientists first reported the use of indocyanine green(ICG) in liver resection. Follow-up studies also found its potential applications such as identifying tumors,determining surgical margins,delineating segmental boundaries,and preventing bile leakage. At present,ICG fluorescence imaging is applied to some types of hepatectomy with excellent effect and is expected to assist in generating surgical strategies for liver malignancies. However,its safety and efficacy still need further studies to evaluate.

White test versus conventional saline test in detecting intra-operative bile leakage in liver resection

Abstract Background Hepatic surgery will be always one of the most challenging surgical procedures due to its anatomical and pathophysiologic varieties. Various problems may complicate the post-operative course. Bile leak remains a serious complication after hepatectomy. Bile leaks can significantly impact morbidity, mortality, and cost of treatment. Bile leak increases risk of sepsis, need for further intervention, either radiological or return to theatre, prolongs duration of intensive care unit and hospital stay, and can precipitate liver failure and death. Objective To assess the post-operative bile leak complication after using white test versus conventional saline test Patients and Methods A prospective study on 50 Hepatectomy cases divided into two groups, the first group consist of 25 cases using white test and the second group consist of 25 cases using conventional saline test from January 2019 to January 2020, at Hepatobiliary unit of the general surgery department of Ain Shams university hospitals. Results The White test has clear advantages in comparison with other bile leakage tests: it precisely detects bile leakages, regardless of size; it does not stain the resection surface, allowing it to be washed off and repeated ad infinitum; and it is safe, quick, and inexpensive. The white test is a feasible and sensitive bile leakage test with no obvious disadvantages. It could be a possible standardized method to prevent bile leakage in major liver resection. Conclusion Now after we discussed our study and reviewed other opinions discussing the optimal methods for intraoperative bile leakage testing, we have now settled on White test using fat emulsion solution to be best of all tests.

The Role of EUS and EUS-FNA in Differentiating Benign and Malignant Gallbladder Lesions.

Endoscopic ultrasonography (EUS) has greater spatial resolution than other diagnostic imaging modalities. In addition, if gallbladder lesions are found and gallbladder cancer is suspected, EUS is an indispensable modality, enabling detailed tests for invasion depth evaluation using the Doppler mode and ultrasound agents. Furthermore, for gallbladder lesions, EUS fine-needle aspiration (EUS-FNA) can be used to differentiate benign and malignant forms of conditions, such as xanthogranulomatous cholecystitis, and collect evidence before chemotherapy. EUS-FNA is also useful for highly precise and specific diagnoses. However, the prevention of bile leakage, an accidental symptom, is highly important. Advancements in next-generation sequencing (NGS) technologies facilitate the application of multiple parallel sequencing to EUS-FNA samples. Several biomarkers are expected to stratify treatment for gallbladder cancer; however, NGS can unveil potential predictive genomic biomarkers for the treatment response. It is believed that NGS may be feasible with samples obtained using EUS-FNA, further increasing the demand for EUS-FNA.

Clinical meaning of the existence of microbiome in gallbladder after laparoscopic cholecystectomy: Incidence and related factors

In general, bile is sterile in normal status. However, there have been reports that bactibilia may exist at certain instances and its causal factors have not fully elucidated yet. To investigate the factors affecting bactiblia, we analyzed possible preoperative predictors and microflora in bile. Bile samples were collected for culture during cholecystectomies from November 2018 to November 2019. A total of 463 laparoscopic cholecystectomies were performed. Preoperative, intraoperative, and postoperative variables were compared between culture-positive and culture-negative groups. Of all patients, 157 (36.7%) of patients were culture-positive. Gram-negative bacteria (92, 58.6%) were more common, and Escherichia coli (43, 46.7%) and Klebsiella (20, 21.7%) were common species. The culture-positive group was older (53.9 ± 16.2 vs. 68.4 ± 12.3, p < 0.001), more symptomatic (66.8% vs. 79.6%, p < 0.001), underwent more preoperative procedures including endoscopic retrograde cholangiopancreatography (18 vs. 54, p < 0.001), percutaneous transhepatic gallbladder drainage (24 vs. 41, p < 0.001), and had more cases of emergency hospitalization (32.8% vs. 63.1%, p < 0.001) than culture-negative group. In multivariate analysis, age (HR 2.874, 95% CI 1.769-4.670, p < 0.001), abdominal pain (HR 1.730, 95% CI 1.026-2.919, p = 0.002), ERCP (HR 9.00, 95% CI 4.833-16.75, p < 0.001), and PTGBD (HR 2.86, 95% CI 1.440-4.901, p = 0.002) were independent factors related with bactibila. Among the patients who underwent laparoscopic cholecystectomy, the elderly, symptomatic, and preoperative drainage patients were more likely to have bacteria in the bile. In such cases, surgeon should be careful to prevent bile leakage during surgery, and consider administration of antibiotics that could cover gram-negative bacteria.

In situ exfoliated silk fibroin nanoribbons enhanced chitin hydrogel for bile duct restoration

The biomaterials exploitation for preventing potential bile leakage caused by the biliary duct injury during hepatobiliary surgery is still challenging. Herein, we developed a“one-pot” method to fabricate the chitin/silk composite hydrogel with superior mechanical properties, biocompatibility and biodegradability via chemically-physically double cross-linked strategy. The resultant hydrogel could be fabricated into bile duct cannula to prevent bile leakage without suturing. The low temperature alkali solvent system simultaneously dissolved the chitin and exfoliated the silk fibroin (SF) into the nanoribbons (SNRs). The in situ exfoliated SNRs served as an enhancement nano-building block to achieve the composite hydrogel with high strength (1.36 Mpa) and toughness (0.71 MJ/m2 of fracture energy). This natural polymer based composite hydrogel exhibited excellent in vitro cytocompatibility when co-cultured with human liver cells and normal human dermal fibroblasts. Moreover, the hydrogel displayed tunable degradability and biochemical properties depending on the degree of bile leakage and thus managed to control the ambient physiological environment around traumatized bile ducts and thus it effectively promoted the bile duct restoration and enhanced the re-vascularization in a rabbit biliary duct injury model. This work provided a whole new perspective for the therapeutic concept of bile duct injury and opened up a new avenue to utilize the natural polymer in the biomedical field.

The safety and efficacy of Glubran 2 as biliostatic agent in liver resection

BackgroundBiloma, an encapsulated collection of bile outside the biliary tree, supported by a predominantly iatrogenic biliary fistula, and bile likeage are two of the most important surgical complications after liver resection. We, hypothesized to conduct a project aimed to prevent, or reduce, the formation of biloma or biliary fistula applying on the hepatic resection area the cyanoacrylate glue (Glubran2).MethodsWe searched in our surgical database all patients underwent liver resection for mCRC from January 2013 to December 2018 and we found a total of 510 patients. 205 patients for Group A (study population: included patients in which we have used Glubran2 during surgical procedure) and 113 patients for Group B (control group), were enrolled.ResultsIn both Groups no patients died during hospitalization and the 30-day mortality was 0 %. During follow-up in Group A, a biliary fistula was found in 2 patients (1 %) versus 3 patients in the Group B (2,6 %). In patients enrolled in Group A no adverse event were reported relate to the use of Glubran2.ConclusionsIt is possible to affirm that the use of Glubran2 as biliostatic agent after liver resection is useful to prevent bile leakage complication and biloma formation and its use demonstrated to be safe and feasible during liver surgery.

Early Laparoscopic Cholecystectomy Has an Advantage over Antecedent Drainage for Grade II/III Acute Cholecystitis

Early laparoscopic cholecystectomy (LC) after gallbladder drainage is recommended in cases with acute cholecystitis (AC); however, the safety of LC after gallbladder drainage is still controversial, and it is not clear whether the drainage contributes to prevent bile leakage during operative procedure. A single institutional retrospective cohort study was performed to assess the safety of LC after gallbladder drainage as well as the frequency of bile leakage during LC. Twenty-four patients that had gallbladder drainage (Drainage group) and 67 patients that had early LC (Early LC group) were treated for AC. Charlson comorbidity index was significantly higher in the Drainage group (P = 0.015). Early LC group had a shorter operative time than Drainage group (P = 0.020) and tend to have less bile leakage rate than Drainage group. In cases when the initial treatment was started within a day after the onset of symptom, no bile leakage was observed in either group. LC after gallbladder drainage can be performed safely; however, it does not reduce the bile leakage rate. Early laparoscopic cholecystectomy with immediate admission as possible might help to prevent the postoperative bile leakage.

Prevention of bile leakage after laparoscopic primary suturing of common bile duct by transabdominal placement of nasal bile duct

Objective To study the advantages of laparoscopic primary suturing of common bile duct plus transabdominal nasobiliary drainage in reducing the rate of bile leakage. Methods The clinical data of laparoscopic primary suturing of common bile duct with or without nasal bile duct drainage in Second People's Hospital of Chengdu were analyzed retrospectively. Results During laparoscopic common bile duct exploration, 286 patients were treated by primary suturing without nasobiliary drainage (group without drainage), including 32 (11.2%) patients with bile leakage; 350 patients were treated by primary suturing with transabdominal nasobiliary drainage (group with drainage), including 11 (3.1%) patients with bile leakage. The incidences of bile leakage of the two groups were significantly different (P 0.05). Conclusions The choice after laparoscopic primary suturing of common bile duct between with or without nasobiliary drainage should be determined according to the diameter of common bile duct. When a common bile duct diameter of less than 11.0 mm, nasobiliary drainage is recommended to reduce the rate of bile leakage. Key words: Choledocholithiasis; Laparoscope; Choledochoscope; Nasobiliary duct

Albumin-Indocyanine Green Evaluation (ALICE) grade predicts bile leakage after hepatic resection.

We investigated the predictors of bile leakage after hepatic resection. The data of 270 consecutive patients who underwent curative hepatic resection in our institute between January, 2016 and April, 2019 were reviewed retrospectively. The patients were assigned to one of two groups according to the presence of bile leakage and the clinicopathological and surgical outcomes were analyzed. Bile leakage was defined by the International Study Group of Liver Surgery (ISGLS) grade. There were no hospital deaths. The median intraoperative blood loss volume was 167ml. Bile leakage occurred in 12 patients (4.4%), as ISGLS grade A leakage in 1 and as ISGLS grade B leakage in 11. The mean hospital stay was significantly longer for patients with bile leakage. High-risk procedures, hepatocellular carcinoma, and Albumin-Indocyanine Green Evaluation (ALICE) grade 3 were independent predictors of ISGLS grade B or C postoperative bile leakage. In patients with three high-risk factors, the incidence of bile leakage was 53.9%. Based on this retrospective analysis, high-risk procedures, hepatocellular carcinoma, and ALICE grade 3 were independent predictors of bile leakage in patients undergoing hepatic resection. Thus, special care must be taken during surgery to prevent bile leakage in patients with these risk factors.

Clip on Staple Method to Prevent Bile Leakage in Anatomical Liver Resection Using Stapling Devices.

Bile leakage after liver surgery is still a problem to be solved. Here, we introduce a simple new technique, the Clip on Staple method, a preventive measure for bile leakage after anatomical liver resection using a stapling device. Before liver parenchymal transection, the roots of Glissonean pedicles for target segments were dissected and divided using the Endo-GIA™ Tri-Staple™ Curved Tip. After the parenchymal transection was completed, the full length of the stapled stump was reinforced by multiple clips. The DS Titanium Ligation Clip was used as the clipping device. Twenty patients underwent this technique during anatomical liver resections with stapling devices. No patient developed postoperative bile leakage of any grade. There was no reoperation or readmission within 90 days. The Clip on Staple method is simple and offers a preventive effect for postoperative bile leakage after anatomical liver resection using stapling devices.

Novel fine gauge electrocautery dilator for endoscopic ultrasound-guided biliary drainage: experimental and clinical evaluation study (with video).

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an alternative drainage technique for endoscopic retrograde cholangiopancreatography (ERCP) 1 . EUS-BD can be divided into two main categories. The first category is the transduodenal route, for example, EUS-guided choledochoduodenostomy (CDS). The second is transgastric, for example, EUS-guided hepaticogastrostomy (HGS). In addition, EUS-guided gallbladder drainage (GBD) can be performed from both routes. Among these procedures, technical tips can be divided into four steps. The first category is puncturing the biliary tract. The second is guidewire insertion, followed by tract dilation. The final step is stent deployment. Successful tract dilation is the most important among these steps. To date, various techniques have been reported for tract dilation including graded, balloon, or electrocautery dilation 2 3 4 . To prevent bile leakage during EUS-BD, a simple dilation technique may be used. The electrocautery dilation technique can certainly dilate the biliary or luminal wall; however, bleeding may occur around the dilation site due to its burning effects. To overcome this, we have developed a novel fine gauge electrocautery dilator device 5 . An experimental study was performed before clinical use of this novel electrocautery dilator. In this technical view, we describe the results of our experimental study and some technical tips for tract dilation in EUS-BD using this novel electrocautery dilator.