Factors leading to loss of patency after biliary reconstruction of major laparoscopic cholecystectomy bile duct injuries: an observational study with long-term outcomes.

BACKGROUND: Small sample size and a lack of standardized reporting for patients requiring reconstruction for laparoscopic cholecystectomy bile duct injuries (LC-BDI) have limited investigation of factors contributing to loss of patency. METHODS: Using a prospective database, patient characteristics, pre-repair investigations, Strasberg-Bismuth level of injury, timing of reconstruction and postoperative complications were compared in successful index reconstruction and revision patients. Multivariate analysis was performed to determine independent predictors of loss of patency. RESULTS: Of 131 patients analysed, 103 had a successful index reconstruction and 28 required revision. There were no statistically significant differences in patient characteristics between the two groups. Days to referral and reconstruction were significantly different (p < 0.001, p = 0.001). Patients with incomplete biliary imaging more often required a revision (p < 0.001). The only independent predictor of loss of patency was incomplete depiction of the biliary tree prior to initial reconstruction (p = 0.035, OR 10.131, 95% CI 1.180-86.987). Primary and secondary patency were 98.1% and 96.4%, respectively with no differences in 30-day complications. CONCLUSIONS: Incomplete depiction of LC-BDI before index reconstruction was independently associated with loss of patency requiring revision. Despite the complexity of repeat biliary reconstruction, outcomes in an HPB unit were similar to that of an index reconstruction.

Evolution of bile duct repair in a low and middle-income country (LMIC): a comparison of diagnosis, referral, management and outcomes in repair of bile duct injury after laparoscopic cholecystectomy from 1991 to 2004 and 2005-2017.

BACKGROUND: There is a paucity of data from the developing world regarding laparoscopic cholecystectomy (LC) bile duct injuries (BDIs), despite the fact that most of the world's population live in a developing country. We assessed how referral patterns, management and outcomes after LC-BDI repair have evolved over time in patients treated at a tertiary referral center in a low and middle-income country (LMIC). METHODS: Patients with LC-BDIs requiring hepaticojejunostomy were identified from a prospective database. Clinical characteristics, geographic distance from referral hospital, timing of referral and repair, and post-operative outcomes were compared in two cohorts treated during 1991-2004 and 2005-2017. RESULTS: Of 125 patients, 32 underwent repair in the early period, 93 in the latter. There was no difference in demographic or clinical characteristics, but a 45.6% increase in geographically distant referrals in the 2005-2017 period. Time from diagnosis to referral and referral to repair increased significantly (p = 0.031, p < 0.001), necessitating more intermediate repairs. Despite this, the number of severe complications decreased (p = 0.022) while long-term outcomes remained unchanged. CONCLUSION: In this study from an LMIC, geographic and logistic constraints necessitated deviation from accepted algorithms devised for well-resourced countries. When appropriately adapted, results comparable to those reported from developed countries are achievable.

Development and validation of a pancreatic injury mortality score (PIMS) based on 473 consecutive patients treated at a level 1 trauma center.

BACKGROUND: This study sought to develop a pancreatic injury mortality score (PIMS) to identify patients at greatest risk of in-hospital mortality after a major pancreatic injury. METHODS: The study used data from a prospective database of 473 patients treated for pancreatic injuries between January 1990 and December 2015. Two thirds of the patients were assigned to the derivation cohort and one third to the validation cohort. Clinical correlates of in-hospital death were identified and considered in stepwise logistic regression analyses that identified the factors included in the risk index. RESULTS: Five variables, age >55, shock on admission, a vascular injury, number of associated injuries and American Association for the Study of Trauma (AAST) pancreatic injury scale correlated with in-hospital death and were used to calculate PIMS. The final score ROC in the derivation dataset was 0.84 (95% CI 0.79-0.89) and in the validation dataset was 0.91 (95% CI 0.84-0.97), which were comparable (p = 0.1). Finally, cut-off scores were used to generate three risk groups and the rate of mortality within the low (PIMS 0-4), medium (PIMS 5-9), and high risk (PIMS 10-20) groups were not significantly different. The scoring system was tested in a validation cohort and showed good calibration and discrimination for in-hospital mortality. CONCLUSIONS: We have derived and validated the PIMS, a novel organ-specific risk prediction score calculated from five variables for in-hospital mortality following major pancreatic trauma. PIMS is simple, quick and easily understandable, increases clinical risk prediction for patients with complex pancreatic and can be used as a benchmark for survival.

Single-stage definitive surgical treatment for portal biliopathy.

The term portal biliopathy (PB) is used to describe the biliary abnormalities associated with portal hypertension. Between 5% and 30% of patients with PB develop biliary obstruction. We report on a patient with extrahepatic biliary obstruction caused by PB that was successfully managed with an intrahepatic segment 3 bypass. The traditional surgical approach for a patient with extrahepatic biliary obstruction caused by PB would be a portosystemic shunt followed by a hepaticojejenostomy if the jaundice persited. An intrahepatic segment 3 bypass provides definitive treatment ensuring biliary decompression and stone removal in a single procedure in appropriately selected patients.

Emergency pancreatoduodenectomy for complex injuries of the pancreas and duodenum.

BACKGROUND: This single-centre study evaluated the outcome of a pancreatoduodenectomy for Grade 5 injuries of the pancreas and duodenum. METHODS: Prospectively recorded data of patients who underwent a pancreatoduodenectomy for trauma at a Level I Trauma Centre during a 22-year period were analysed. RESULTS: Nineteen (17 men and 2 women, median age 28 years, range 14-53 years) out of 426 patients with pancreatic injuries underwent a pancreatoduodenectomy (gunshot n = 12, blunt trauma n = 6 and stab wound n = 1). Nine patients had associated inferior vena cava (IVC) or portal vein (PV) injuries. Five patients had initial damage control procedures and underwent a definitive operation at a median of 15 h (range 11-92) later. Twelve had a pylorus-preserving pancreatoduodenectomy (PPPD) and 7 a standard Whipple. Three patients with APACHE II scores of 15, 18, 18 died post-operatively of multi-organ failure. All 16 survivors had Dindo-Clavien grade I (n = 1), grade II (n = 7), grade IIIa (n = 2), grade IVa (n = 6) post-operative complications. Factors complicating surgery were shock on admission, number of associated injuries, coagulopathy, hypothermia, gross bowel oedema and traumatic pancreatitis. CONCLUSIONS: A pancreatoduodenectomy is a life-saving procedure in a small cohort of stable patients with non-reconstructable pancreatic head injuries. Damage control before a pancreatoduodenectomy will salvage a proportion of the most severely injured patients who have multiple injuries.

Gastric heterotopia causing jejunal ulceration and obstruction.

A young woman with persistent postprandial vomiting was found to have a high-grade proximal jejunal stricture. The stricture was surgically excised, and histopathological examination showed gastric heterotopia with localised ulceration and fibrosis. Symptomatic gastric heterotopia in the small bowel is rare, and to our knowledge this is the first report of jejunal gastric heterotopia resulting in ulceration with subsequent stricturing and obstruction.

Endoscopic management of bile leaks after laparoscopic cholecystectomy.

BACKGROUND: A bile leak is an infrequent but potentially serious complication after biliary tract surgery. Endoscopic intervention is widely accepted as the treatment of choice. This study assessed the effectiveness of endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy and biliary stenting in the management of postoperative bile leaks. METHODS: An ERCP database in a tertiary referral centre was reviewed retrospectively to identify all patients with bile leaks after laparoscopic cholecystectomy. Patient records and endoscopy reports were reviewed. RESULTS: One hundred and thirteen patients (92 women, 21 men; median age 47 years, range 22 - 82 years) with a bile leak were referred for initial endoscopic management at a median of 12 days (range 2 - 104 days) after surgery. Presenting features included intra-abdominal collections with pain in 58 cases (51.3%), abnormal liver function tests (LFTs) in 22 (19.5%), bile leak in 25 (22.1%), and sepsis in 8 (7.1%). Twenty-nine patients (25.7%) were found to have either major bile duct injuries without duct continuity, vascular injuries or other endoscopic findings requiring surgical or radiological intervention. Of 84 patients managed endoscopically, 44 had a cystic duct (CD) leak, 26 a CD leak and common bile duct (CBD) stones, and 14 a CBD injury amenable to endoscopic stenting. Of the 70 patients with CD leaks (group A), 24 underwent sphincterotomy only (including 8 stone extractions), 43 had a sphincterotomy with stent placement (including 18 stone extractions) and 1 had only a stent placed, while 2 patients with previous sphincterotomies required no further intervention. The average number of ERCPs in group A was 2.3 (range 1 - 7). Of the 14 patients with bile duct injuries treated endoscopically (group B), 7 had a class D, 5 an E5 and 2 a class B injury; 13 patients underwent sphincterotomy and stenting, and 1 had a sphincterotomy only. Group B required an average of 3.6 ERCPs (range 2 - 5). The 113 patients underwent a total of 269 ERCPs (mean 2.4, range 1 - 7). Seven patients had one or more complications related to the ERCP: 3 acute pancreatitis, 2 cholangitis, 2 sphincterotomy bleeds, 1 duodenal perforation and 1 impacted Dormia basket, the latter 2 requiring operative intervention. CONCLUSIONS: Three-quarters of bile leaks after laparoscopic cholecystectomy were due to CD leaks (with or without retained stones) or lesser bile duct injuries and were amenable to definitive endoscopic therapy. Nineteen patients (16.8%) had major injuries that required operative intervention.

Selective nonoperative management of liver gunshot injuries.

OBJECTIVE: Nonoperative management (NOM) of liver gunshot injuries is yet to gain general acceptance. The aim of this study was to assess the feasibility and safety of selective NOM of liver gunshot injuries. PATIENTS AND METHODS: A prospective, protocol-driven study, which included all liver gunshot injuries admitted to a level I trauma center, was conducted over a 4-year period. Patients with right-sided thoracoabdominal, and right upper quadrant gunshot wounds with or without localized right upper quadrant tenderness underwent contrasted abdominal computed tomography scan evaluation to detect the presence of a liver injury. Patients with confirmed liver injuries were observed with serial clinical examinations. Outcome parameters included need for delayed laparotomy, complications, length of hospital stay, and survival. RESULTS: During the study period, 63 patients with liver gunshot injuries were selected for NOM. The mean injury severity score was 19.6 (range, 4-34). Simple liver injuries (grades I and II) occurred in 26 (41.3%) patients and complex liver injuries (grades III, IV, and V) occurred in 37 (58.7%) patients. Associated injuries included 14 (22.2%) kidney, 44 (69.8%) diaphragm, 43 (68.3%) lung contusion, 42 (66.7%) hemothorax and/or pneuomothorax, and 21 (33.3%) rib fractures. Five patients required delayed laparotomy resulting in successful NOM rate of 92%. Complications included liver abscess (3), biliary fistula (3), retained hemothorax (4), and nosocomial pneumonia (5). The mean hospital stay was 6.1 (range, 3-23 days). There was no mortality. CONCLUSION: The NOM of appropriately selected patients with liver gunshot injuries is feasible, safe, and effective, regardless of the liver injury severity.

Predictive factors for rebleeding and death in alcoholic cirrhotic patients with acute variceal bleeding: a multivariate analysis.

BACKGROUND: Bleeding from esophageal varices is a leading cause of death in alcoholic cirrhotic patients. The aim of the present single-center study was to identify risk factors predictive of variceal rebleeding and death within 6 weeks of initial treatment. METHODS: Univariate and multivariate analyses were performed on 310 prospectively documented alcoholic cirrhotic patients with acute variceal hemorrhage (AVH) who underwent 786 endoscopic variceal injection treatments between January 1984 and December 2006. All injections were administered during the first 6 weeks after the patients were treated for their first variceal bleed. RESULTS: Seventy-five (24.2%) patients experienced a rebleed, 38 within 5 days of the initial treatment and 37 within 6 weeks of their initial treatment. Of the 15 variables studied and included in a multivariate analysis using a logistic regression model, a bilirubin level >51 mmol/l and transfusion of >6 units of blood during the initial hospital admission were predictors of variceal rebleeding within the first 6 weeks. Seventy-seven (24.8%) patients died, 29 (9.3%) within 5 days and 48 (15.4%) between 6 and 42 days after the initial treatment. Stepwise multivariate logistic regression analysis showed that six variables were predictors of death within the first 6 weeks: encephalopathy, ascites, bilirubin level >51 mmol/l, international normalized ratio (INR) >2.3, albumin <25 g/l, and the need for balloon tube tamponade. CONCLUSIONS: Survival was influenced by the severity of liver failure, with most deaths occurring in Child-Pugh grade C patients. Patients with AVH and encephalopathy, ascites, bilirubin levels >51 mmol/l, INR >2.3, albumin <25 g/l and who require balloon tube tamponade are at increased risk of dying within the first 6 weeks. Bilirubin levels >51 mmol/l and transfusion of >6 units of blood were predictors of variceal rebleeding.

Fibrolamellar hepatocellular carcinoma at a tertiary centre in South Africa: a case series.

BACKGROUND: Fibrolamellar carcinoma (FLC) is an uncommon malignant tumour of hepatocyte origin that differs from hepatocellular carcinoma (HCC) in aetiology, demographics, condition of the affected liver, and tumour markers. Controversy exists whether FLC demonstrates a more favourable prognosis than typical HCC. A review of existing literature reveals a dearth of FLC data from the African continent. METHODS: We utilised the prospective liver resection database at Groote Schuur Hospital to identify all patients who underwent surgery for FLC between 1990 and 2008. RESULTS: Seven patients (median age 21 years, range 19 - 42, 5 men, 2 women) underwent surgery for FLC. No patient had underlying liver disease or an elevated alpha fetoprotein (AFP) at either initial presentation or recurrence. Six patients had a solitary tumour at diagnosis (mean largest diameter = 12cm), and underwent left hepatectomy (N=2), right hepatectomy (N=1), extended right hepatectomy (N=1), right hepatectomy (N=1), extended right hepatectomy (N=1), and segmentectomies (N=2). Three patients underwent a portal lymphadenectomy for regional lymphatic tumour involvement. One patient with advanced extrahepatic portal nodal metastasis was unresectable. No peri-operative deaths occurred. Recurrence occurred post resection in all 6 patients. Median overall survival was 60 months, and overall 5-year survival was 4 out of 7 (57%). Post-resection survival (N=6) was 61 months, with a 5-year survival rate of 4 out of 6 (67%). The patient with unresectable disease survived 38 months after tumour embolisation with Lipiodol. CONCLUSION: Our series suggests that despite (i) a high resection rate of solitary lesions with clear tumour resection margins, and (ii) absence of underlying liver disease, FLC has a high recurrence rate with an ultimately poor clinical outcome. These findings concur with recent international experience of FLC. experience of FLC.

Resection of complex pancreatic injuries: Benchmarking postoperative complications using the Accordion classification.

AIM: To benchmark severity of complications using the Accordion Severity Grading System (ASGS) in patients undergoing operation for severe pancreatic injuries. METHODS: A prospective institutional database of 461 patients with pancreatic injuries treated from 1990 to 2015 was reviewed. One hundred and thirty patients with AAST grade 3, 4 or 5 pancreatic injuries underwent resection (pancreatoduodenectomy, n = 20, distal pancreatectomy, n = 110), including 30 who had an initial damage control laparotomy (DCL) and later definitive surgery. AAST injury grades, type of pancreatic resection, need for DCL and incidence and ASGS severity of complications were assessed. Uni- and multivariate logistic regression analysis was applied. RESULTS: Overall 238 complications occurred in 95 (73%) patients of which 73% were ASGS grades 3-6. Nineteen patients (14.6%) died. Patients more likely to have complications after pancreatic resection were older, had a revised trauma score (RTS) < 7.8, were shocked on admission, had grade 5 injuries of the head and neck of the pancreas with associated vascular and duodenal injuries, required a DCL, received a larger blood transfusion, had a pancreatoduodenectomy (PD) and repeat laparotomies. Applying univariate logistic regression analysis, mechanism of injury, RTS < 7.8, shock on admission, DCL, increasing AAST grade and type of pancreatic resection were significant variables for complications. Multivariate logistic regression analysis however showed that only age and type of pancreatic resection (PD) were significant. CONCLUSION: This ASGS-based study benchmarked postoperative morbidity after pancreatic resection for trauma. The detailed outcome analysis provided may serve as a reference for future institutional comparisons.

Surgical Management and Outcomes of Combined Pancreaticoduodenal Injuries: Analysis of 75 Consecutive Cases.

BACKGROUND: Combined pancreaticoduodenal injuries (CPDI) are complex and result in significant morbidity and mortality. Survival in CPDI after initial damage-control laparotomy (DCL) and pancreaticoduodenectomy was evaluated in a large cohort treated in a Level I trauma center. We hypothesized that bivariate analyses would accurately identify factors influencing morbidity and mortality. STUDY DESIGN: The records from a prospective database of 453 consecutive patients treated for pancreatic injuries between January 1990 and April 2015 were reviewed to identify those with CPDI. Primary and secondary end points assessed were death and morbidity. RESULTS: Seventy-five patients (69 men, median age 27 years, range 14 to 56 years) with CPDI, underwent 161 operations (range 1 to 9 operations). Twenty-nine patients with complex CPDI underwent a DCL and 46 had definitive treatment during the initial operation. Nineteen had a pancreaticoduodenectomy, either during the initial operation (n = 13) or after the DCL (n = 6). Postoperative complications occurred in 63 (84%) patients. Twenty-one (28%) patients died, including 15 (43%) of 35 patients with associated vascular injuries. Sixteen (84%) of the 19 patients who had a pancreaticoduodenectomy survived. Significantly more complications related to bleeding, disseminated intravascular coagulation, and hypovolemic shock occurred in those patients who eventually died and significantly more abdominal sepsis and fistulas occurred in patients who survived. Mortality was related to associated vascular injuries overall (p < 0.01), major visceral venous injuries (p < 0.011), and the combination of vascular plus the total number of associated organs injured (p < 0.046). CONCLUSIONS: Despite using DCL in CPDIs, morbidity (84%) and mortality (28%) remain substantial. Careful selection of patients undergoing pancreaticoduodenectomy resulted in 84% survival. Associated vascular injuries, major visceral venous injuries, and combined vascular and associated organs injured influenced outcomes and mortality.

The role of endoscopic retrograde pancreatography in pancreatic trauma: a critical appraisal of 48 patients treated at a tertiary institution.

BACKGROUND: Endoscopic retrograde pancreatography (ERP) is useful in the diagnosis and treatment of selected patients with pancreatic trauma. We analyzed the role of ERP in treating persistent complications of pancreatic injuries at a tertiary institution. METHODS: Patients with pancreatic trauma who underwent ERP were identified from a prospective database of 426 pancreatic injuries from January 1983 to January 2011. Patient demographics, mechanism of injury, time to presentation, method of diagnosis, associated injuries, clinical management, endoscopic interventions and their timing, surgical treatment, and patient outcomes were evaluated. RESULTS: Forty-eight patients underwent ERP after blunt (n = 26) or penetrating (n = 22) pancreatic injury. Median time from injury to ERP was 38 days (range, 2-365 days). Diagnostic ERP was successful in 47 patients. In 11 patients, ERP demonstrated an intact main duct with minor peripheral injuries, and no further intervention was required. A pancreatic fistula was demonstrated in 24, a main pancreatic duct stricture in 12, and a pseudocyst in 10 patients. Fifteen patients had a pancreatic duct sphincterotomy, seven had a pancreatic stent inserted, and six had an endoscopic pseudocyst drainage. Ten patients ultimately required surgery, seven of whom had demonstrated a severe pancreatic duct stricture. Operations performed following ERP were distal pancreatectomy (n = 6), pancreaticojejunostomy (n = 3) and cyst-jejunostomy (n = 1). CONCLUSION: ERP allowed one quarter of the patients to be treated conservatively. Half had a successful intervention by ERP. Success was most likely in those with fistulae and pseudocysts. Surgery was ultimately avoided in more than three quarters of the patients. LEVEL OF EVIDENCE: Therapeutic study, level V.

Management of biliary complications in 412 patients with liver injuries.

BACKGROUND: Bile leaks occur in 4% to 23% of patients after major liver injuries. The role of conservative management versus internal biliary drainage has not been clearly defined. The safety and efficacy of nonoperative management of bile leaks were studied. METHODS: Four hundred twelve patients with liver injuries were assessed in a prospective study between 2008 and 2013. All patients with clinically significant injuries to the intrahepatic biliary tract were evaluated. Bile leaks were classified as minor or major (>400 mL/d or persistent drainage >14 days). Minor leaks were managed conservatively, and major leaks underwent endoscopic retrograde cholangiogram and endoscopic biliary stenting. RESULTS: Fifty-one patients (12%) developed a bile leak after liver trauma. Eleven patients (22%) with an extrahepatic duct injury underwent open surgery. Forty patients (78%) had an intrahepatic bile leak. Twenty-six patients (65%) with minor bile leaks were treated conservatively, and 14 patients (35%) with major leaks underwent endoscopic retrograde cholangiogram and internal drainage. All bile leaks resolved. There was no significant difference in the two groups with respect to septic complications (p = 0.125), intensive care unit stay (p = 0.534), hospital stay (p = 0.164), or mortality (p = 1.000). CONCLUSION: Sixty-five percent of the intrahepatic bile leaks following trauma are minor and easily managed conservatively. Endoscopic retrograde cholangiogram and internal drainage should be reserved for major leaks. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Outcome in decompensated alcoholic cirrhotic patients with acute variceal bleeding.

BACKGROUND: Variceal bleeding (VB) is the leading cause of death in cirrhotic patients with oesophageal varices. We evaluated the efficacy of emergency endoscopic intervention in controlling acute variceal bleeding and preventing rebleeding and death during the index hospital admission in a large cohort of consecutively treated alcoholic cirrhotic patients after a first variceal bleed. METHODS: From January 1984 to August 2011, 448 alcoholic cirrhotic patients (349 men, 99 women; median age 50 years) with VB underwent endoscopic treatments (556 emergency, 249 elective) during the index hospital admission. Endoscopic control of initial bleeding, variceal rebleeding and survival after the first hospital admission were recorded. RESULTS: Endoscopic intervention alone controlled VB in 394 patients (87.9%); 54 also required balloon tamponade. Within 24 hours 15 patients rebled; after 24 hours 61 (17%, n=76) rebled; and 93 (20.8%) died in hospital. No Child-Pugh (C-P) grade A patients died, while 16 grade B and 77 grade C patients died. Mortality increased exponentially as the C-P score increased, reaching 80% when the C-P score exceeded 13. CONCLUSION: Despite initial control of variceal haemorrhage, 1 in 6 patients (17%) rebled during the first hospital admission. Survival (79.2%) was influenced by the severity of liver failure, with most deaths occurring in C-P grade C patients.