Bile Leakage Rate Research Articles

ASSESSMENT OF SURGICAL OUTCOME FROM LAPAROSCOPIC VERSUS OPEN CHOLECYSTECTOMY DURING 1ST WEEK OF ACUTE CHOLECYSTITIS

Background: Acute Calcular Cholecystitis (A.C) is inflammation of the gallbladder and is the most common complication of gallstones, requiring hospital admission and prompt intervention. Its Symptoms include right upper abdominal pain, nausea, vomiting, and occasionally fever. Often gallbladder attacks (biliary colic) precede acute cholecystitis without appropriate treatment, recurrent episodes of cholecystitis are common. Complications of acute cholecystitis include gallstone pancreatitis, common bile duct stones, and inflammation of the common bile duct.Aim of The Work: To assess surgical outcome from laparscopic and open cholecystectomy in acute calcular cholecystitis by assessment and differentiate between both of them in these parameters as regards: 1-Hospital stay, 2-Wound infection, 3-Bilary fistula, 4-Missed stone, 5-intestinal injury.Patients and Methods: Type of Study: prospective clinical trial. Study Setting: This study will be carried out, at Ain Shams hospitals. Study Period: This study will be carried out during the period between October2018 and October 2019. Study Population: This study will include 30 patients with diagnosis of acute calcularcholycystitis.Results: The present study was a prospective, clinical, trial that included30 patients diagnosed with acute calcular cholecystitis attended to surgery theatre at Ain Shams hospital. The patients were divided into two groups: Group I including 15 patients underwent laparoscopic cholecystectomy during the first week of their presentation. Group II including 15 patients underwent open cholecystectomy during the first week of their presentation.Conclusion: Cholecystectomy during 1st week of acute cholecystitis should be attempted by laparoscopy at first in condition that there are no complications as gangerenous gall bladder. as, post-operative morbidity and hospital stay are reduced by laparoscopic cholecystectomy. Moreover, intestinal injury and wound infection rate are reduced by laparoscopy. A positive trend exists in operating time favoring laparoscopy, however more studies are necessary. Severe hemorrhage and bile leakage rate are not influenced by the technique.

Robotic hepatic resection in postero-superior region of liver.

Laparoscopic hepatectomy in the posterosuperior hepatic region is technically challenging and demanding. However, minimally invasive procedures carried out using the Da Vinci robot provide potential advantages in complex hepatectomy. This study reported the experience of a single center on robotic hepatectomy in the posterosuperior hepatic region. This retrospective study evaluated the general characteristics and perioperative outcomes of consecutive patients who underwent robotic hepatectomy in the posterosuperior hepatic region at our center from March 2015 to January 2020. For 100 patients who were included into this study, 53 underwent anatomical segmentectomy or subsegmentectomy and 47 non-anatomical partial hepatectomy. There was no conversion to laparotomy. The R0 resection rate was 100%. The following perioperative outcomes were compared between patients who underwent anatomical segmentectomy/subsegmentectomy versus those who underwent non-anatomical partial hepatectomy: operation times of 160 versus 126min, intraoperative blood losses of 100 versus 50ml, intraoperative blood transfusion rates of 7.54% versus 4.26%, postoperative lengths of hospital stay of 5 versus 4days, Clavien-Dindo Grade I-II complications rates of 15.09% versus 19.15%, Grade III-V complications rates of 3.77% versus 0%, bile leakage rates of 4% versus 7% and pleural effusion rates of also 4% versus 7%, respectively. The results indicated the safety and feasibility of robotic anatomical and non-anatomical liver resections in the posterosuperior hepatic region. The robotic transabdominal approach is an option for hepatectomy in the posterosuperior hepatic region.

Laparoscopic Exploration of the Common Bile Duct: A Systematic Review of the Published Evidence Over the Last 10 Years.

Endoscopic and open surgical interventions are widely implemented as the standard practice in common bile duct exploration. However, the laparoscopic approach has been also reported to have comparative/superior outcomes in this concept. This has created an ongoing debate about the ideal approach to adopt in practice. A systematic review of the published evidence over the last decade that has looked into the outcomes of laparoscopic exploration of the common bile duct through transductal and transcystic approaches. Our systematic review included 36 relevant papers. The majority were based on nonrandomized protocols conducted in single centers with high expertise. The data analysis showed that laparoscopic common bile duct exploration through both approaches was successful in more than 84% of the patients, with an average length of hospital stay of 5.6 days. Conversion to open surgery was reported in 5%-8% of the patients, and the bile leak rates from the more recent studies was 0%-12%, with mortality figures of 0%-1.3%. The outcomes were statistically in favor of the transcystic route when compared to the transductal route from the viewpoints of bile leak rates, mean operative time, duration of hospital stay and morbidity. In experienced hands, both laparoscopic approaches in common bile duct exploration are safe in patients who are clinically fit to have this intervention. It is associated with a statistically significant lower overall morbidity and shorter duration of hospital stay when compared to open surgery. Relevant up-to-date high-quality randomized trials are unavailable.

Bilioenteric Reconstruction Techniques in Pediatric Living Donor Liver Transplantation.

Biliary complications (BCs) are still a major cause of morbidity following liver transplantation despite the advancements in the surgical technique. Although Roux‐en‐Y (RY) hepaticojejunostomy has been the standard technique for years in pediatric patients, there is a limited number of reports on the feasibility of duct‐to‐duct (DD) anastomosis, and those reports have controversial outcomes. With the largest number of patients ever reported on the topic, this study aims to discuss the feasibility of the DD biliary reconstruction technique in pediatric living donor liver transplantation (LDLT). After the exclusion of the patients with biliary atresia, patients who received either deceased donor or right lobe grafts, and retransplantation patients, data from 154 pediatric LDLTs were retrospectively analyzed. Patients were grouped according to the applied biliary reconstruction technique, and the groups were compared using BCs as the outcome. The overall BC rate was 13% (n=20), and the groups showed no significant difference ( P =0.6). Stricture was more frequent in the DD reconstruction group; however, this was not statistically significant ( P =0.6). The rate of bile leak was also similar in both groups ( P =0.6). The results show that the DD reconstruction technique can achieve similar outcomes when compared with RY anastomosis. Because DD reconstruction is a more physiological way of establishing bilioenteric integrity, it can safely be applied.

Stratification of Major Hepatectomies According to Their Outcome: Analysis of 2212 Consecutive Open Resections in Patients Without Cirrhosis.

To stratify major hepatectomies (MajHs) according to their outcomes. MajHs are associated with non-negligible operative risks, but they include a wide range of procedures. Detailed depiction of the outcomes of different MajHs is the basis for a new classification of liver resections. We retrospectively considered patients that underwent hepatectomy in 17 high-volume centers. Patients with an associated digestive/biliary resection were excluded. We analyzed open MajHs in non-cirrhotic patients. MajHs were classified according to the Brisbane nomenclature. Right hepatectomies (RHs) were reference standards. Outcomes were adjusted for potential confounders, including indication, liver function, preoperative portal vein embolization, and enrolling center. We analyzed a series of 2212 patients. In comparison with RH, left hepatectomy had lower mortality [0.6% vs 2.2%, odds ratio (OR) = 0.25], severe morbidity (11.7% vs 14.4%, OR = 0.62), and liver failure rates (2.1% vs 11.6%, OR = 0.16). Left hepatectomy+Sg1 and mesohepatectomy+/-Sg1 had outcomes similar to RH, except for higher bile leak rate (31.3% and 13.5% vs 6.7%, OR = 4.36 and OR = 2.29). RH + Sg1 had slightly worse outcomes than RH. Right and left trisectionectomies had higher mortality (5.0% and 7.3% vs 2.2%, OR = 2.07 and OR = 2.71) and liver failure rates than RH (19.0% and 22.0% vs 11.6%, OR = 2.03 and OR = 2.21). Left trisectionectomy had even higher severe morbidity (25.6% vs 14.4%, OR = 2.07) and bile leak rates (14.6% vs 6.7%, OR = 2.31). The term "major hepatectomy" includes resections having heterogeneous outcome. Different MajHs can be stratified according to their mortality, severe morbidity, liver failure, and bile leak rates.

Biliary Leakage after Laparoscopic Cholecystectomy versus Open Cholecystectomy

Abstract Background: Laparoscopic cholecystectomy has become the gold standard in the treatment of symptomatic gallstones. In spite of the advantages of a distinctly faster recovery and better cosmetic results, the laparoscopic approach bears a higher risk for iatrogenic bile duct injury and injury of the right hepatic artery. Bile leak after laparoscopic cholecystec-tomy is uncommon but can occur in 0.3-2.7% of patients. A bile leak may result in a biliary fistula, a subhepatic/subphrenic collection and localised or generalised peritonitis. Despite the widespread notion that the risk of bile leak is higher after LC, there is a scarcity in the published literature that directly compared the risk of bile leak after LC versus open cholecys-tectomy. Aim of Study: To provide cumulative data about the outcome of biliary leakage after laparoscopic versus open cholecystectomy. Patients and Methods: In the present study, we searched Medline via PubMed, SCOPUS, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) from their inception till December 2018. The search retrieved 12157 unique records. We then retained 45 potentially eligible records for full-texts screening. Finally, 17 studies were included in the present systematic review and meta-analysis. Data Extrac-tion: If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information and defined assessment measures. Results: In terms of the primary outcomes of the present study, the overall effect estimates showed that LC significantly increased the risk of bile leak compared to OC (OR 2.01, 95% CI [1.3-3.09]; p=0.002); the pooled studies showed no signif-icant heterogeneity (p=0.74; I2=0%). Conclusion: Surgeons experienced a very low rate of postoperative bile leak following laparoscopic or open chole-cystectomy; however, the risk of bile leak appears to be higher with laparoscopic compared to open cholecystectomy. The present systematic review and meta-analysis showed that the laparoscopic cholecystectomy significantly increased the risk of bile leak compared to open cholecystectomy. These data draw attention to the importance of early identification of patients, at high risk of bile leak, as it may allow specific measures or conversion to open cholecystectomy.

Liver resections in patients with prior bilioenteric anastomosis are predisposed to develop organ/space surgical site infections and biliary leakage: results from a propensity score matching analysis.

The aims of this study were to compare the perioperative outcomes after hepatectomy with prior bilioenteric anastomosis to those without prior anastomosis, and to elucidate the mechanisms and preventative measures of its characteristic complications. The demographic data and perioperative outcomes of 525 hepatectomies performed between January 2007 and December 2018, including 40 hepatectomies with prior bilioenteric anastomosis, were retrospectively analyzed. A propensity score matching analysis demonstrated that hepatectomies with prior bilioenteric anastomosis were associated with a higher frequency of major complications (p = 0.015), surgical site infection (p = 0.005), organ/space surgical site infection (p = 0.003), and bile leakage (p = 0.007) compared to those without. A multivariate analysis also elucidated that prior bilioenteric anastomosis was one of the independent risk factors of organ/space surgical site infection. In the patients with prior bilioenteric anastomosis, bile leakage was associated with organ/space surgical site infection at a significantly higher rate than those without prior bilioenteric anastomosis (p < 0.001). Prior bilioenteric anastomosis is a strong risk factor for organ/space surgical site infections, which might be induced by bile leakage. To prevent infectious complications after hepatectomy with prior bilioenteric anastomosis, meticulous liver transection to reduce bile leakage rate is thus considered to be mandatory.

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

Bile leakage after loop closure vs clip closure of the cystic duct during laparoscopic cholecystectomy: A retrospective analysis of a prospective cohort.

BACKGROUNDLaparoscopic cholecystectomy (LC) is one of the most frequently performed surgical procedures. Cystic stump leakage is an underestimated, potentially life threatening complication that occurs in 1%-6% of the patients. With a secure cystic duct occlusion technique during LC, bile leakage becomes a preventable complication.AIMTo investigate the effect of polydioxanone (PDS) loop closure of the cystic duct on bile leakage rate in LC patients.METHODSIn this retrospective analysis of a prospective cohort, the effect of PDS loop closure of the cystic duct on bile leakage complication was compared to patients with conventional clip closure. Logistic regression analysis was used to develop a risk score to identify bile leakage risk. Leakage rate was assessed for categories of patients with increasing levels of bile leakage risk.RESULTSOf the 4359 patients who underwent LC, 136 (3%) underwent cystic duct closure by a PDS loop. Preoperatively, loop closure patients had significantly more complicated biliary disease compared to the clipped closure patients. In the loop closure cohort, zero (0%) bile leakage occurred compared to 59 of 4223 (1.4%) clip closure patients. For patients at increased bile leakage risk (risk score ≥ 1) rates were 1.6% and up to 13% (4/30) for clip closure patients with a risk score ≥ 4. This risk increase paralleled a stepwise increase of actual bile leakage complication for clip closure patients, which was not observed for loop closure patients.CONCLUSIONCystic duct closure with a PDS loop during LC may reduce bile leakage in patients at increased risk for bile leakage.

Hybrid Laparoendoscopic-Radiologic Procedure for Laparoscopic Cholecystectomy Complicated With Choledocolithiasis.

The removal of common bile duct stones (CBDS) is routinely performed as either a 1-stage or 2-stage procedure. Despite many developments in both methods, the optimal approach has not been established to date. This study aimed to investigate the value and short-term outcomes of hybrid laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) combined with intraoperative endoscopic nasobiliary drainage (IO-ENBD) after primary duct closure (PDC) and intraoperative cholangiography (IOC) in patients with concomitant gallbladder stones (GBS) and CBDS. Forty-seven patients with GBS and CBDS who underwent LC and LCBDE, PDC with IO-ENBD, and IOC were retrospectively enrolled. Stone characteristics and removal, operative data, and postoperative outcomes were recorded and analyzed. A total of 46 (97.87%) procedures were completed without conversion to open surgery. The mean operating time was 127.15±8.36 minutes (range, 97 to 158 min). Three patients (6.38%) had residual stones during IOC but achieved 100% stone clearance eventually. Postoperative pancreatitis and bile leakage rates were 4.26% and 2.13%, respectively. A hybrid procedure combining LC and LCBDE, PDC with IO-ENBD, and IOC is safe and feasible for concomitant GBS and CBDS.

Minor hepatectomies: focusing a blurred picture. Analysis of the outcome of 4471 open resections in non-cirrhotic patients

Background: Liver surgery is moving toward a parenchyma-sparing approach, favoring minor hepatectomies (MiH) instead of major resections. MiH encompasse a wide range of procedures at different complexity, whose outcomes have not been fully elucidated. Methods: Consecutive patients undergoing a first liver resection in 17 highly-experienced centers were considered. Cirrhosis, associated digestive/biliary resection and mini-invasive surgery were exclusion criteria. We distinguished limited resections (LR), (mono)segmentectomies (S), left lateral sectionectomies (LLS), right anterior sectionectomies (RAS), right posterior sectionectomies (RPS), and other bisegmentectomies (BS). In addition: LR with exposure of intrahepatic vessels were defined 'complex LR' (CLR); mono/bisegmentectomies Sg7/Sg8 were defined 'postero-superior segmentectomies' (PSS); segmentectomies Sg1 and combined resections of Sg4s+Sg8+Sg1 were defined 'complex core hepatectomies' (CCH). Outcome of LLS and right hepatectomies (RH) were used as reference standards. Outcome of MiH were adjusted for covariates (liver function, diagnosis, chemotherapy, and center). Results: 4471 MiH were analyzed. In comparison with RH, MiH had lower 90-day mortality (0.5%/2.2%, p<0.001), severe morbidity (8.6%/14.4%, p<0.001), and liver failure rates (2.4%/11.6%, p<0.001), but similar bile leak rate. Non-complex LR had outcome similar to LLS. CLR and S/BS of anterolateral segments (Sg2-6) had higher bile leak rates than LLS (odds ratio (OR)=2.2 and OR=2.7), but similar severe morbidity rates. CCH had the highest bile leak rate (OR=5.5), even higher than RH (OR=1.9), and had severe morbidity rate approaching RH (vs. LLS OR=2.4). PSS and RAS had severe morbidity rates similar to RH (OR=1), while RPS had slightly lower rates. The three procedures had bile leak rates similar to RH. MiH had low liver failure rates (<5%) except for RAS (9.7% vs. 11.6% after RH). Conclusion: MiH include resections having heterogeneous outcome. Mortality rate is low, but MiH can be stratified according to severe morbidity, liver failure and bile leak rates, most complex resections having outcome similar to RH. Bile leak and severe morbidity rates of different MiH in comparison with LLS and RH

Safety and feasibility of laparoscopy technology in right hemihepatectomy

Laparoscopic hepatectomy (LH) has been accepted widely owing to its advantages as a minimally invasive surgery; however, laparoscopic right hemihepatectomy (LRH) has rarely been reported. We aimed to compare the benefits and drawbacks of LRH and open approaches. Between January 2014 and October 2017, 85 patients with tumor and hepatolithiasis who underwent LRH (n = 30) and open right hemihepatectomy (ORH) (n = 55) were enrolled in this study. For tumors, LRH showed significantly better results with respect to blood loss (P = 0.024) and duration of hospital stay (P = 0.008) than ORH, while hospital expenses (P = 0.031) and bile leakage rate (P = 0.012) were higher with LRH. However, the operative time and rate of other complications were not significantly different between the two groups. However, for hepatolithiasis, there was less blood loss (P = 0.015) and longer operative time (P = 0.036) with LRH than with ORH. There were no significant difference between LRH and ORH in terms of hospital stay, hospital expenses, and complication rate (P > 0.05). Moreover, the postoperative white blood cell count, alanine aminotransferase level, aspartate aminotransferase level, and total bilirubin were not significantly different in both types of patients (P > 0.05). Our results suggest the safety and feasibility of laparoscopy technology for right hemihepatectomy in both tumor and hepatolithiasis patients.

1407 Foreign Body Erosion into the Biliary Tree—How to Avoid a Hepaticojejunostomy

INTRODUCTION: Cholecystectomy remains one of the most common surgical procedures in the United States with a rate of greater than 750,000 annually. Of these cases, approximately 1-2% are complicated by a bile leak. Although the rate of bile leaks is relatively low, the morbidity and mortality can be very high with patients rapidly deteriorating after presentation usually due to sepsis. Endoscopic retrograde cholangiopancreatography (ERCP) can detect greater than 95% of leaks and provide therapeutic intervention aimed at eliminating the pressure gradient across the Sphincter of Oddi which promotes the flow of bile into the duodenum to heal the injured portion of the biliary tree. This case aims to show the significant clinical benefit of endoscopic management of bile leaks, although with the novel use of direct cholangioscopy. CASE DESCRIPTION/METHODS: This is a case of a 45-year-old woman with no significant past medical history who presented to an outside hospital with cholecystitis and underwent open cholecystectomy. Surgery was complicated by duodenal injury which was primary repaired and a Jackson-Pratt (JP) drain was left in place. Bilious fluid returned from the JP drain on post-operative day two and she underwent an ERCP which confirmed a bile leak and a sphincterotomy was performed and a stent was placed. She was referred to our center for stent removal four months later and at the time her cholangiogram was negative for leak so a stent was not replaced (Figure 1). Within a week of the procedure she had bilious return from the JP drain and a tube study preformed via the JP drain was read as a “normal T-tube” cholangiogram (Figure 2). As there was suspected erosion of the JP drain into the biliary tree and high concern for creating a biliary injury when removing the drain, direct cholangioscopy was used for safe removal and identification of the leak (Figure 3). The biliary injury was sealed with a fully covered self-expanding metal stent with excellent results and no further evidence of ongoing leak. DISCUSSION: ERCP remains the preferred treatment option for bile leaks and prevents patients from having to undergo corrective operation.4 In this case there was high concern for creating a biliary injury when removing the drain, thereby direct cholangioscopy was used for safe removal and identification of the leak. To our knowledge this is the first report of JP drain erosion into the CBD with use of direct cholangioscopy and ERCP as endoscopic management for removal and treatment of biliary injury.

Clinical practice of basin-shaped hepaticojejunostomy following hilar resection of stage III/IV hilar cholangiocarcinoma

BackgroundRadical surgery for Bismuth type III/IV hilar cholangiocellular carcinoma, which was usually considered unresectable, seems to improve prognosis by increasing the surgical curability rate. However, the dilemma of multiple billiary stumps and high postoperative complication rate caused by hepato-enteric anastomosis has been the main impediment. Thus, we practiced and introduce a new technique called “basin-shaped” hepaticojejunostomy to improve the treatment.MethodsThirty-two cases with Bismuth type III/IV hilar cholangiocarcinoma admitted to our department from Aug. 2013 to Dec. 2015 and who underwent hilar resection and resection segment 4(or plus resection segment 1) were reconstructed by “basin-shaped” hepaticojejunostomy. The clinical data were collected and analyzed.ResultsAll patients underwent successful R0 high hilar resection following basin-shaped hepaticojejunostomy and were discharged from the hospital without severe postoperative complications. The average operation time for hepato-enteric anastomosis was 42.1 ± 8.5 min. The postoperative bile leakage rate was 3.1% (1/32), and the biliary infection rate was 6.2% (2/32). Within a median follow-up of 25.6 months, none of the patients developed local recurrence around the hepato-enteric anastomosis.ConclusionsFor patients with Bismuth type III/IV hilar cholangiocellular carcinoma who underwent resection segment 4(or plus resection segment 1), basin-shaped hepaticojejunostomy was a safe, simple and valid method for bile duct reconstruction, with a relatively low incidence of postoperative complications.

The Application of Indocyanine Green (ICG) Staining Technique During Robotic-Assisted Right Hepatectomy: with Video

IntroductionThe application of indocyanine green (icg) properties in the field of HPB surgery is gaining momentum. The adoption of the staining technique for the visualization of hepatic liver parenchyma is still preliminary. MethodsWe performed a 1:1 case- matched comparison among 20 patients who underwent robotic liver resection with or without the application of icg fluorescence. ResultsThe icg enabled the reduction of postoperative liver abscess and bile leakage rate. The staining technique was not time-consuming and provided excellent enhancement of liver transection line. ConclusionThe routine use of icg-fluorescence could potentially reduce the postoperative complications during robotic liver surgery.

Primary closure after laparoscopic common bile duct exploration is feasible for elderly patients: 5-Year experience at a single institution

Laparoscopic common bile duct exploration (LCBDE) has been demonstrated safety and effective for patients with gallbladder stones and extrahepatic bile duct stones, however few studies reported its suitability for the treatment of elderly patients. Thus, our study aims to investigate the safety and feasibility of primary closure after LCBDE in the treatment of elderly patients. 408 out of 499 patients with Gallbladder stones complicated with choledocholithiasis who were undergone LCBDE and primary closure were divided into two groups: Group A (<65 years old, n=249) and Group B (≥65 years old, n=159) and the related clinical data were compared and analyzed by statistical method. Pre-operative American Society of Anesthesiologists (ASA) score of elderly patients was significantly higher than the younger patients (P<0.05). In both groups, the positive rate of Choledocholithiasis and bile sludge at exploration, number of stones in CBD, utilization rate of Electro-hydraulic lithotripsy, estimated blood loss, successful duct clearance, the rate of postoperative bile leakage, postoperative bile duct stricture, reoperation, stone recurrence, and other postoperative complications showed no significant difference (p>0.05). There were also no statistical differences between both groups in time to removal of drainage, postoperative hospital stay, readmission within 30 days and mortality (p>0.05). It is safe and feasible to treat the elderly patients with common bile duct stones under the premise of strict surgical indications, skilled laparoscopic procedures and accurate endoscopic suture techniques.

The incidence and severity of post-hepatectomy bile leaks is affected by surgical indications, preoperative chemotherapy, and surgical procedures.

Bile leaks are one of the most common complications after liver resection. The International Study Group of Liver Surgery (ISGLS) established a uniform bile leak definition including a severity grading. However, a risk factor assessment according to ISGLS grading as well as the clinical implications has not been studied sufficiently so far. The incidence and grading of bile leaks according to ISGLS were prospectively documented in 501 consecutive liver resections between July 2012 and December 2016. A multivariate regression analysis was performed for risk factor assessment. Association with other surgical complications, 90-day mortality as well as length of hospital stay (LOS) was studied. The total rate of bile leaks in this cohort was 14.0%: 2.8% grade A, 8.0% grade B, and 3.2% grade C bile leaks were observed. Preoperative chemotherapy or biliary intervention, diagnosis of hilar cholangiocarcinoma, colorectal metastasis, central minor liver resection, major hepatectomy, extended hepatectomy or two-stage hepatectomy, were some of the risk factors leading to bile leaks. The multivariate regression analysis revealed that preoperative chemotherapy, major hepatectomy and biliodigestive reconstruction remained significant independent risk factors for bile leaks. Grade C bile leaks were associated not only with surgical site infection, but also with an increased 90-day mortality and prolonged LOS. The preoperative treatment as well as the surgical procedure had significant influence on the incidence and the severity of bile leaks. Grade C bile leaks were clinically most relevant, and led to significant increased LOS, rate of infection, and mortality.

Human fibrin sealant reduces post-operative bile leakage of primary closure after laparoscopic common bile duct exploration in patients with choledocholithiasis.

Context:Primary closure of the common bile duct (CBD) without drainage is considered a suitable approach after laparoscopic CBD exploration (LCBDE); however, the risk of post-operative bile leakage is high. Up to now, it has not been clear whether human fibrin sealant can reduce post-operative bile leakage of the primary suture.Aims:In this study, we evaluated the role of human fibrin sealant in primary closure of the CBD after LCBDE.Subjects and Methods:Patients with choledocholithiasis who had undergone primary duct closure of the CBD after LCBDE were divided into two groups according to whether fibrin sealant was used.Statistical Analysis Used:Fisher's exact test or the Chi-square test was used for categorical variables to calculate frequencies and percentages between the groups. The Student's t-test was used to compare the means of the continuous variables between the groups.Results:The human fibrin sealant group had a lower rate of post-operative bile leakage compared to the other group (P < 0.05). There were no significant differences in additional parameters such as operative time, post-operative stay duration, time to drain removal, bile duct stenosis, acute allergic reaction and overall mortality.Conclusions:Human fibrin sealant can reduce post-operative bile leakage in primary closure of CBD after LCBDE in patients with choledocholithiasis.

Management of difficult gallbladder and comparison of laparoscopic subtotal cholecystectomy with open subtotal cholecystectomy

Aim: Laparoscopic cholecystectomy is the optimal surgical treatment for benign gallbladder diseases. Under curtain conditions it is very hard to distinguish the Calot triangle and it becomes difficult to perform safe cholecystectomy. Subtotal cholecystectomy is a salvage option in such conditions. The aim of this study is to compare the results of open and laparoscopic subtotal cholecystectomy in difficult gallbladder management.Material and Methods: In this retrospective study results of all consecutive patients who were performed subtotal cholecystectomy between July 2014 and August 2017 were collected and laparoscopic and open methods were compared. Results:Forty-five of 396 laparoscopic cholecystectomy cases underwent subtotal cholecystectomy during the study period. Subtotal cholecystectomy was performed laparoscopically in 27 of 45 patients (Group I), and open method in 18 patients (Group II). Convertion rate was %34.1. No significant difference was observed in terms of both preoperative and postoperative laboratory results. There was no difference between two groups in terms of ERCP history. The rate of open operation was statistically higher in acute cases. The duration of surgery was significantly higher in laparoscopic group but length of hospital stay was significantly higher in open group. Total cost was higher in group 2 but this result did not reach statistical significance. Total bile leak rate was 2.2%.Conclusion: Laparoscopic subtotal cholecystectomy is a safe and appropriate method which can be compared with open subtotal cholecystectomy in difficult gallbladder management.