Prevent Bile Leakage Research Articles

Loop retraction of the gallbladder in single incision laparoscopic cholecystectomy*

BACKGROUND: Single incision laparoscopic surgery (SILS) is a modified laparoscopic technique with only one access through the umbilicus to avoid visible scars. One crucial step of a cholecystectomy is a good insight to the triangle of Calot. We present our technique to retract the gallbladder with a PDS-Endoloop fixed to the fundus and which is passed through the abdominal wall with the Endo CloseTM Trocar Site Closure Device. METHODS: Prospective study. RESULTS: Cholecystectomy was performed in 29 patients with the SILS-technique between 7/2009 and 3/2010. Twenty-four patients were female (82.8%), the median age was 50 years (range, 17–74) and the median body mass index was 25.9 kg/m2 (range, 20.5–34.0). Cholecystitis was present in 13 out of 29 patients (6 acute, 7 chronic), all others (55.2%) had no inflammatory signs. In the majority of the cases (69.0%) the PDS-Endoloop technique was feasible; in 4 cases there was no need for additional retraction with the PDS-Endoloop. In 5 cases the application of the PDS-Endoloop was not possible due to advanced inflammation of the gallbladder. No complications occurred. CONCLUSIONS: This technique is simple, safe and feasible and can be carried out in selected cases of cholecystitis. The main advantage is the prevention of bile leakage.

Predictive Factors for Bile Leakage After Hepatectomy: Analysis of 505 Consecutive Patients

Bile leakage is the most common complication after hepatectomy and its incidence is not declining. The aim of the present study was to identify predictive factors for bile leakage. Clinical data from 505 consecutive patients who underwent hepatectomy without extrahepatic bile duct resection in our department between January 2006 and December 2009 were reviewed retrospectively. The incidence of bile leakage was found to be 6.7%. Multivariate analysis identified three independent factors that were significantly correlated with the occurrence of bile leakage: (1) repeat hepatectomy (P = 0.002; odds ratio [OR] 3.439; 95% confidence interval [CI] 1.552-7.618), (2) a cut surface area ≥57.5 cm(2) (P = 0.004; OR 5.296; 95% CI 1.721-16.302), and (3) intraoperative blood loss ≥775 ml (P = 0.01; OR 2.808; 95% CI 1.280-6.160). More meticulous management is needed to prevent bile leakage in high-risk patients.

Combined left hepatectomy with fenestration and using a harmonic scalpel, fibrin glue and closed suction drainage to prevent bile leakage and ascites in the management of symptomatic polycystic liver disease: a case report

IntroductionSurgical treatment is the usual therapy for patients with polycystic liver disease and with severe symptoms, yet the results of surgery are often disappointing and the optimal surgical approach is uncertain.Case presentationWe present the case of a 41-year-old Greek woman who underwent combined left hepatectomy with fenestration for symptomatic polycystic liver disease using ultrasound scalpel, fibrin glue and closed suction drain to prevent bile leakage, haemorrhage and ascites. Liver resection using the ultrasound scissors allowed quick parenchyma dissection under haemostatic conditions with safe coagulation of small vessels and bile ducts. Moreover, the ultrasound scalpel was applied to the cyst cavities exposed on the peritoneum to ablate the fluid-producing epithelial cyst lining. We also covered the cut cystic cavities exposed to the peritoneum surface of the liver with fibrin glue. Instead of allowing the opened cysts to drain into the abdominal cavity, we used two wide bore closed suction fluted drains. We did not observe excessive fluid loss through the drainage after the second postoperative day. The drain tubes were removed on the third postoperative day.ConclusionIn our patient, effective treatment of ascites and prevention of bile leakage and bleeding indicate that this new approach is promising and may become a useful surgical technique for polycystic liver disease.

Intraoperative application of “white test” to reduce postoperative bile leak after major liver resection: results of a prospective cohort study in 137 patients

This study aimed to prove the clinical validation of the recently developed bile leakage test, "white test" (WT), in major liver resection. From June 2005 to June 2007, the study was carried out in a prospective consecutive fashion, including 74 patients without bile leakage test as the control group while 63 patients undergoing white test as the study group. The incidences of bile leakage within the 30th postoperative day in both groups were compared. Postoperative bile leakage was found in 22.9% patients in the control group and in 5.3% patients in the WT group, respectively (p < 0.01). In univariate analysis, not performing a white test, Klatskin tumor, biliary-enteric anastomosis, and longer operation time were associated with an increase of bile leakage. The multivariate analysis showed that not performing the WT was the only significant factor influencing the occurrence of postoperative bile leakage (p = 0.02). 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.

Bile leakage after hepatectomy for hepatolithiasis: Risk factors and management

Bile leakage remains a major postoperative complication after liver resection. Bile leakage after hepatectomy for liver neoplasms has been well studied. However, the risk factors and management of this complication after liver resection for intrahepatic lithiasis has not been investigated. From January 1992 to June 2004, 312 consecutive patients with intrahepatic lithiasis underwent hepatic resections Sun Yet-san University. Perioperative risk factors pertaining to the development of bile leakage were identified using univariate and multivariate analysis. The management and outcome of these patients with bile leakage were evaluated. Bile leakage developed in 23 (7.4%) of 312 patients. The multivariate logistic regression analysis identified that left hepatectomy (P=.024, odds ratio [OR]=3.695, 95% confidence interval [CI]: 1.185 to 11.517) and the period greater than 1 month between operative time and the latest acute cholangitis attack (P=.02, OR=4.144, 95% CI: 1.248 to 13.757) were the independent risk factors for development of bile leakage after hepatectomy for hepatolithiasis. The septic complications were higher in the patients with bile leakage than in those without bile leakage (ie, wound infection: 56.5% vs 13.5%, P=.001; subphrenic abscess: 21.7% vs 4.8%, P=.01; septicemia: 8.7% vs 0.7%, P=.029). Percutaneous drainage or combined endoscopic naso-biliary drainage was the first choice of treatment for bile leakage; 20 (87.0%) of 23 patients were treated by this method. One patient underwent re-operation for diffuse peritonitis due to withdrawal of T tube inadvertently at postoperative day 1. Two patients with bile leakage were re-operated due to uncontrollable hemobilia at postoperative day 5 and 12, respectively. Patients who underwent hepatectomy at the period less than 1 month after the latest attack of acute cholangitis carry high risk for the development of bile leakage. Preoperative cholangiography to identify the aberrant hepatic duct for high risk patients and avoidance of hepatectomy at the acute phase of cholangitis are of critical importance to prevent bile leakage after hepatectomy. Percutaneous drainage is the primary and effective treatment for bile leakage.

Perioperative Outcome of Laparoscopic Left Lateral Liver Resection Is Improved by Using Staple Line Reinforcement Technique: A Case Report

Current laparoscopic stapling technology still cannot prevent bile leakage (<55%) along the resection margin. A new staple line reinforcement technique was used in the present case. This technique incorporates an absorbable polymer membrane into the stapler system, such that it buttresses the transected solid organ. The objectives of this novel procedure are to decrease hemorrhage at the staple line and to prevent bile duct leakage after liver resection. A 47-year-old man followed for status post biliopancreatic diversion with duodenal switch presented with epigastric pain. On imaging, he was found to have a lesion in segment 2-3 of the left lobe of the liver, which measured at least 3 cm in diameter. He was admitted to the hospital to undergo a laparoscopic left lateral liver resection. This procedure involved laparoscopic ultrasonography of the liver and transection of the left liver lobe with endoscopic linear staplers. The staple height of 3.5, 60 mm long, reinforced with an absorbable polymer membrane was used for liver transection to catch the portal branches. This required multiple firings in the liver parenchyma and additional division of some tissue using the Harmonic scalpel. The larger branch in the middle of segment 2-3 and the left hepatic vein were both transected with the novel staple line reinforcement technique. Bleeding or any bile leakage in this area could not be visualized. No drains were left. The patient's postoperative course was uncomplicated, and he was discharged on postoperative day 3. Pathology results showed a cavernous hemangioma of 4.5 cm in diameter. Staple line reinforcement with the absorbable polymer membrane has the potential to decrease staple line hemorrhage and bile leakage.

A rapid and simple technique for insertion of a T-tube into the minimally incised common bile duct at laparoscopic surgery.

We fabricated a stainless-steel over-tube for rapid and simple insertion of a T-tube following common bile duct exploration during laparoscopic surgery. With this over-tube, operating time is greatly shortened because minimal incision and only two sutures are needed to prevent bile leakage.

Imaging of the percutaneous cholecystostomy tract: observations and utility.

The technique and observations in 28 patients who underwent imaging of the percutaneous cholecystostomy (PC) tract are described. Imaging of the tracts was performed by injecting contrast material through an end-hole dilator during catheter removal (n = 13) or through an end-hole dilator with a side adapter over a thin guide wire (n = 15); the latter method permitted simple catheter reinsertion if the tract was poorly formed. Catheters were removed between 9 and 158 days (mean, 36.6 days; median, 29.5 days) after PC. Twenty-three patients had well-formed tracts and five patients did not. Among the five patients with a poorly formed tract, two experienced no sequela as a result of catheter withdrawal, two underwent immediate catheter reinsertion, and one developed bile peritonitis; this last patient was treated with repeated PC and antibiotics. All patients in whom a catheter was placed for at least 20 days had a well-formed, intact tract. Imaging of the PC tract is helpful to identify patients who have an immature tract. In a patient with a poorly formed tract, catheter reinsertion may be advisable to prevent bile leakage and peritonitis.

Extracorporeal shock-wave lithotripsy and methyl tert-butyl ether for partially calcified gallstones

To explore the possibility that gallbladder stone fragments might be able to be safely dissolved using methyl tert-butyl ether immediately after extracorporeal shock-wave lithotripsy (ESWL), a feasibility study in 8 patients with one to four partially calcified gallbladder stones was performed. The gallstones averaged 2.2 cm in diameter (range 1.3–3 cm) and contained layered or diffuse calcium detectable by computed tomography scan only (7 patients) or plain film (1 patient). After a 5F (1.7 mm) pigtail catheter was placed percutaneously into the gallbladder, ESWL fragmentation was performed using a renal stone lithotriptor. The patients were under general anesthesia and in the prone position on a support gantry designed for gallbladder stone ESWL. Following ESWL, methyl tert-butyl ether was infused and aspirated via the gallbladder catheter until no further stone material was radiologically detectable or could be dissolved. After 8–26 h (mean = 13 h) of methyl tert-butyl ether therapy, no radiologically detectable gallstones remained in 6 of 8 patients. Shell fragments of three peripherally calcified stones in 1 patient and the densely calcified, predominantly pigment stone in a second patient were refractory to combined therapy. Both ESWL and treatment with methyl tert-butyl ether were well tolerated in all patients, although bile leakage after catheter removal occurred in 3 patients, one of whom was treated by cholecystectomy. Additional measures to prevent bile leakage may be advisable if these two modalities are to be used in tandem. We found no evidence, however, that predissolution stone fragmentation with ESWL predisposed the gallbladder to either mucosal damage by methyl tert-butyl ether or increased absorption of it.