Specialist early and immediate repair of post-laparoscopic cholecystectomy bile duct injuries is associated with an improved long-term outcome.

INTRODUCTION: A majority of bile duct injuries (BDI) sustained during laparoscopic cholecystectomy require formal surgical reconstruction, and traditionally this repair is performed late. We aimed to assess long-term outcomes after repair, focusing on our preferred early approach. METHODS: A total of 200 BDI patients [age 54(20-83); 64 male], followed up for median 60 (5-212) months were assessed for morbidity. Factors contributing to this were analyzed with a univariate and multivariate analysis. RESULTS: A total of 112 (56%) patients were repaired by specialist hepatobiliary surgeons [timing of repair: immediate, n = 28; early (<21 days), n = 43; and late (>21 days) n = 41], whereas 45 (22%) underwent repair by nonspecialist surgeons before specialist referral [immediate, n = 16; early, n = 26 and late, n = 03]. Outcomes after immediate and early repairs were comparable to late repairs when performed by specialists [recurrent cholangitis:11%, 12%, and 10%; P = 0.96, NS; re-stricture:18%,5%, and 29%; P = 0.01; nonsurgical intervention: 14%, 5%, and 24%; P<0.03; redo surgery: 4%, 2%, and 5%; P = 0.81, NS; overall morbidity: 21%, 14%, and 39%; P<0.02]. On multivariate analysis, immediate and early repairs done by nonspecialist surgeons were independent risk factors (P < 0.05) for recurrent cholangitis [50% and 27%], re-stricturing (75% and 61%), redo reconstructions (31% and 61%), and overall morbidity (75% and 84%). CONCLUSION: Immediate and early repair after BDI results in comparable, if not better long-term outcomes compared to late repair when performed by specialists.

Outcomes comparing a pancreaticogastrostomy (PG) and a pancreaticojejunostomy (PJ) after a pancreaticoduodenectomy (PD).

BACKGROUND: The advantage of a pancreaticogastrostomy (PG) over a pancreaticojejunostomy (PJ) after a pancreaticoduodenectomy (PD) is not clear. AIM: The aim of the present study was to compare the pancreatic fistula (PF, defined according to the International Study Group for Pancreatic Fistula classification) rate and other complications between both methods. METHODS: Retrospective analysis of prospectively collected data of 424 [median: 65 years (17-83)] patients who underwent PG (239, 56.4%) and PJ (185, 43.6%) reconstruction between January 2005 and December 2009. RESULTS: PF occurred in 55 (23.5%) in the PG and 30 (16.2%, P= 0.067) patients in the PJ group. Grade A PF occurred in 19 (7.9%), B in 22 (9.2%) and C in 14 (5.8%) in the PG compared with 5 (2.7%), 12 (6.5%) and in 13 (7.0%), respectively, in the PJ group. The median hospital was 10 days in both groups. The morbidity was higher in the PG group (108, 45.2 vs. 62, 33.5%, P= 0.015). However, there was no significant difference in the 90-day mortality between both groups (PG-17, 7.0% vs. PJ-16, 8.6%, P= 0.558). CONCLUSION: There was no difference in the overall PF rate, hospital stay and overall mortality between PG and PJ reconstruction methods. However, the grade A PF rate was higher in the PG group.

Colorectal cancer in patients with inflammatory bowel disease after liver transplantation for primary sclerosing cholangitis.

BACKGROUND: Patients with primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) may have an increased risk of developing colorectal cancer (CRC) after liver transplantation (LT). We evaluated our patients with PSC after LT to identify risk factors for CRC and its impact on survival. PATIENTS AND METHODS: A total of 152 patients (108 men, 100 with IBD) with PSC who underwent 173 LTs between 1986 and May 2000 were analyzed in three groups: (1) PSC without IBD (n=52); (2) PSC with colectomy (pre-LT and at LT) (n=17, colectomy pre-LT in 13 and simultaneous colectomy at LT in four); and (3) PSC with IBD and an intact colon (n=83). The following factors were studied: age, gender, liver, and renal biochemistry, international normalized ratio, Child-Pugh stage, operative time, blood use, hospital stay, immunosuppression, risk of CRC, retransplantation rate, and mortality. RESULTS: The incidence of CRC after LT was 5.3% (8/152) compared with 0.6% (7/1,184) in non-PSC cases (P<0.001). All CRCs in the PSC group were in patients with IBD and an intact colon. The cumulative risk of developing CRC in the 83 patients with an intact colon and IBD was 14% and 17% after 5 and 10 years, respectively (PSC non-IBD group 0% risk after 10 years, P<0.06). The multivariate analysis showed three significant variables related to the risk of developing CRC: colonic dysplasia after LT (P<0.0003), duration of colitis more than 10 years (P<0.002), and pancolitis (P<0.004). The cause of death in patients with CRC was cancer related in 75% of cases with a reduced 5-year survival of 55% versus 75% without CRC (not significant). CONCLUSION: Patients with PSC undergoing LT with a long history of ulcerative colitis and pancolitis have an increased risk of developing CRC with reduced survival. We advocate long-term aggressive colonic surveillance and colectomy in selected high-risk patients with longstanding severe colitis.

Pre-operative stenting is associated with a higher prevalence of post-operative complications following pancreatoduodenectomy.

OBJECTIVES: Whilst there are theoretical benefits from pre-operatively draining the biliary tree prior to pancreatoduodenectomy (PD), the current literature does not support this intervention. The aim of this study was to explore the relationship between pre-operative stenting, bactibilia and outcome in a large United Kingdom tertiary referral practice. METHODS: Patients undergoing PD were identified from a prospectively maintained database. The presence or absence of a stent prior to PD, and the results of bile cultures taken at PD were related to the subsequent post-operative course and the development of complications. RESULTS: 280 patients underwent PD for periampullary malignancies, all of whom presented with jaundice. 118 patients were stented prior to referral (98 ERCP, 20 PTC). Bile cultures were positive more frequently in the stent group (83% vs. 55%; p = 0.000002) and bactibilia was more common after ERCP than PTC (83% vs. 56%; p = 0.006). The overall prevalence of complications was 54% in the stented and 41% in the non-stented group (p = 0.03) with statistical significance achieved for pancreatic leak (p = 0.013) and haemorrhagic complications (p = 0.03). Comparing stent with no stent, there as no difference in the 30-day mortalities (8.5% vs. 6.8%; p = 0.6) or the 1-year mortality rates (35% vs. 28%; p = 0.21). Mortality rates in the infection versus no infection groups were comparable at 30 days (8.5% vs. 5.5%; p = 0.21), and at 1 year (30.7% vs. 26.4%; p = 0.25). CONCLUSIONS: Pre-operative stent insertion prior to PD is associated with increased morbidity but not mortality and this is greatest for stents placed at ERCP.

Is it time to extend liver acceptance criteria for controlled donors after cardiac death?

BACKGROUND: Donation after cardiac death (DCD) has reemerged as potential way to increase donor liver availability. Earlier, programs with DCD liver transplantation used conservative donor criteria to allow safe results. Successful initial outcomes allowed extended DCD criteria to address transplant demand. METHODS: A total of 63 DCD liver grafts were used during the study period in carefully selected recipients. These were divided into two groups: "Standard" DCD within conservative criteria (n=33; age ≤60 years, body mass index <30 kg/m(2), donor warm ischemia time ≤30 min, and cold ischemia time ≤8 hr) and "Extended" DCD beyond these criteria (n=30). We compared donor and recipient characteristics and postoperative outcomes, including patient and graft survival. RESULTS: Both groups had satisfactory initial function; liver graft function at 1, 7, and 30 days after liver transplantation were similar. Median follow-up period was 25 and 18.5 months for Standard and Extended criteria DCD grafts, respectively, with 1-year patient and graft survival of 88% and 82% for the Standard group vs. 90% and 90% for the Extended. Overall, 8 of 63 (13%) patients developed biliary complications; however, the incidence was not different between the Standard and Extended groups. Seven early deaths occurred, four and three in the Standard and Extended groups, respectively. CONCLUSIONS: Recipients of DCDs beyond conventional acceptance criteria have equivalent early outcomes to standard DCD grafts. With careful selection of donors and recipients, these grafts can be safely used to expand the donor pool.

Biliary dilatation and strictures after composite liver-small bowel transplantation in children: defining a newly recognized complication.

BACKGROUND: Biliary dilatation and strictures (BDS) are well recognized after liver transplantation but not reported after composite liver-small bowel transplantation (CLSBT). We aimed to describe and propose a classification of BDS in children undergoing CLSBT and analyze the potential risk factors. METHODS: Biliary complications of 47 consecutive children undergoing CLSBT were reviewed and classified according to presentation, location, and intervention required. The following variables were studied: small recipient (weight, <10 kg), donor-recipient weight ratio, liver/bowel graft reduction/not, partial/full pancreas, liver/bowel rejection, and median cold ischemia time (>454 min). RESULTS: Twenty-one (45%) children developed BDS at median 190 days (22 [7-138] months follow-up). Five distinct biliary lesions were identified. Most of the BDS (14/21; 67%) consisted of sphincter dysfunction-related bile duct dilatation (type I), whereas others (7/21; 33%) comprised extrahepatic bile duct (type II; n=3), hilar (type III; n=1), segmental (type IV; n=1), and diffuse (type V; n=2) intrahepatic strictures. None of the graft reduction strategies or other variables studied demonstrated a significant association with BDS. Therapeutic intervention was required in 1 of 14 type I and four of seven type II to V BDS in the form of percutaneous biliary dilatation with or without drainage. CONCLUSION: This article identifies BDS after CLSBT as a frequent late complication after CLSBT, which has a benign outcome in most cases. The natural history of children with extrahepatic and intrahepatic strictures is not yet clear and will need multicenter prospective studies.

Reduction in bile leaks following adult split liver transplant using a fibrin-collagen sponge: A pilot study.

INTRODUCTION: Bile leaks are a frequent complication of adult split liver transplantation. We compared surgical complications in patients who had the cut surface of the donor liver treated with a patch to those in whom the cut surface of the liver was treated with fibrin glue. MATERIAL AND METHODS: Two consecutive cohorts of 16 patients undergoing adult right lobe split liver transplant were compared. In the first cohort, the liver surface was treated with fibrin glue and in the second the liver surface was treated with TachoSil fibrinogen-thrombin-collagen patches. Post-operative complications were analyzed. RESULTS: Bile leaks were significantly fewer among patients in whom the cut surface of the liver was treated with fibrin-collagen sponge compared to those where fibrin glue was used on the cut surface: 1/16 (6.25%) vs. 7/16 (43.75%), respectively; p=0.03. There were some differences in biliary anastomotic techniques used in the two groups but 7/8 leaks (87.5%) arose from the cut surface, and only one was from the anastomosis. CONCLUSION: Using a fibrinogen-thrombin-collagen sponge patch may reduce bile leaks from the cut surface of the liver during adult right lobe split liver transplants.

Multivariate and univariate analysis of prognostic factors following resection in HCC: the Birmingham experience.

BACKGROUND: The aim of this study was to look into our experience of resection for hepatocellular carcinomas (HCCs) in a tertiary Hepatobiliary and Liver Transplant Unit in the UK. METHODS: A retrospective analysis of our prospective database was carried out. RESULTS: 715 cases of HCC were seen. 100 (13.9%) underwent hepatic resection and 159 (22.2%) orthotopic liver transplant. The 1-, 3- and 5-year overall survival following resection was 75.3, 37.0 and 21.5% respectively. Factors affecting long-term survival included resection margin (p < 0.001), recurrence (p < 0.007), alpha-fetoprotein >50 (p < 0.001) and serum albumin (p < 0.03). On multivariate analysis, recurrence (p < 0.001) and histological grade (p < 0.044) were significant. The 1- and 3-year recurrence rates were 27.3 and 72.5% respectively. Histological grade (p < 0.007), alpha-fetoprotein >50 (p < 0.033), female gender (p < 0.016) and portal vein involvement (p < 0.016) were significant in recurrence. CONCLUSIONS: Resection data from the East may not be comparable to the West owing to the higher transplant activity in the latter. Liver function tests and imaging would be sufficient to assess liver function prior to hepatic resection. HCC with cirrhosis should be assessed by a transplant unit prior to any treatment. The MELD (Model for End-Stage Liver Disease) score would be a valuable preoperative tool in the assessment of cirrhotics.

Hepatic-artery aneurysm in adult liver transplantation.

Hepatic artery aneurysm (HAA) is a rare vascular complication, but has a high mortality rate in liver transplant recipients. This study reports the precipitating factors, clinical manifestation, pre-operative diagnosis, related micro-organism, management, and outcome, in a series of HAAs that developed after adult orthotopic liver transplantation (OLT). Data on the primary disease as well as on the above were obtained from a prospective database, and all case records were reviewed. There were eight (0.5%) HAAs in 1,575 adult cadaveric OLTs between 1982 and March 2001. All were pseudo-aneurysms around the native hepatic-artery (HA) anastomosis, and all occurred in whole-organ OLTs. There were three types of clinical presentations: sudden hypotension (n=4), gastrointestinal (GI) bleeding (n=2), and abnormal liver-function tests (LFTs) (n=2). The majority (n=7) presented within the first 2 months (median: 27.5 days, range: 12-760 days) following OLT. A pre-operative diagnosis of HAA was not determined in five cases. The sensitivity of abdominal ultrasound scan (USS), computed tomography (CT) scan and angiography for detection of HAAs was 3 of 5, 1 of 2 and 3 of 4, respectively. Micro-organisms could be identified in six patients (bacteria n=4 and fungi n=3). All patients underwent urgent operations (excision of HAA in six and ligation in two cases). Immediate reconstruction of the HA was carried out, two different methods being used: repair of native arteries (n=2) and arterial conduit (interposition n=3 and aortic conduit n=2). Two patients died peri-operatively, two died within 2 months, and the remaining four patients are alive at between 8.6 and 12.8 years after repair. HAA following OLT is unpredictable in its presentation, and the sensitivity of clinical and radiological detection is low. A high index of suspicion is required, and urgent surgery with immediate re-vascularisation and use of appropriate antibiotic/anti-fungal agents is recommended.

Arterial conduits for hepatic artery revascularisation in adult liver transplantation.

Arterial complications after orthotopic liver transplantation (OLT), including hepatic artery thrombosis (HAT), are important causes of early graft failure. The use of an arterial conduit is an accepted alternative to the utilisation of native recipient hepatic artery for specific indications. This study aims to determine the efficacy of arterial conduits and the outcome in OLT. We retrospectively reviewed 1,575 cadaveric adult OLTs and identified those in which an arterial conduit was used for hepatic revascularisation. Data on the primary disease, indication for using arterial conduit, type of vascular graft, operative technique and outcome were obtained. Thirty-six (2.3%) patients underwent OLT in which arterial conduits were used for hepatic artery (HA) revascularisation. Six of these were performed on the primary transplant, while the rest (n=30) were performed in patients undergoing re-transplantation, including six who had developed hepatic artery aneurysms. The incidence of arterial conduits was 0.4% (6/1,426 cases) in all primary OLTs and 20.1% (30/149 cases) in all re-transplants. Twenty-nine procedures utilised iliac artery grafts from the same donor as the liver, six used iliac artery grafts from a different donor, and a single patient underwent a polytetrafluoroethylene (PTFE) graft. Two techniques were used: infra-renal aorto-hepatic artery conduit and interposition between the donor and recipient native HAs, or branches of the HAs. The 30-day mortality rate for operations using an arterial conduit was 30.6%. Three conduits thrombosed at 9, 25 and 155 months, respectively, but one liver graft survived without re-transplantation. The arterial conduits had 1- and 5-year patency rates of 88.5% and 80.8%. The 1- and 5-year patient survival rates were 66.7% and 44%. We can thus conclude that an arterial conduit is a viable alternative option for hepatic revascularisation in both primary and re-transplantation. Despite a lower patency rate than that of native HA in the primary OLT group, the outcomes of arterial conduit patency and patient survival rates are both acceptable at 1 and 5 years, especially in the much larger re-OLT group.