Assessing the effectiveness of ACS surgical risk calculator versus P-POSSUM in predicting mortality and morbidity for major hepatobiliary surgery: An observational study.

Risk assessment is difficult yet would provide valuable data for both the surgeons and the patients in major hepatobiliary surgeries. An ideal risk calculator should improve workflow through efficient, timely, and accurate risk stratification. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator (SRC) and Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) are surgical risk stratification tools used to assess postoperative morbidity. In this study, preoperative data from 300 patients undergoing major hepatobiliary surgeries performed at a single tertiary university hospital were retrospectively collected from electronic patient records and entered into the ACS-SRC and P-POSSUM systems, and the resulting risk scores were calculated and recorded accordingly. The ACS-NSQIP-M1 (C-statistics = 0.725) and M2 (C-statistics = 0.791) models showed better morbidity discrimination ability than P-POSSUM-M1 (C-statistics = 0.672) model. The P-POSSUM-M2 (C-statistics = 0.806) model showed better differentiation success in morbidity than other models. The ACS-NSQIP-M1 (C-statistics = 0.888) and M2 (C-statistics = 0.956) models showed better mortality discrimination than P-POSSUM-M1 (C-statistics = 0.776) model. The P-POSSUM-M2 (C-statistics = 0.948) model showed better mortality differentiation success than the ACS-NSQIP-M1 and P-POSSUM-M1 models. The use of ACS-SRC and P-POSSUM calculators for major hepatobiliary surgeries offers quantitative data to assess risks for both the surgeon and the patient. Integrating these calculators into preoperative evaluation practices can enhance decision-making processes for patients. The results of the statistical analyses indicated that the P-POSSUM-M2 model for morbidity and the ACS-NSQIP-M2 model for mortality exhibited superior overall performance.

Dexmedetomidine Attenuates Inflammation in Elderly Patients Following Major Hepatobiliary and Pancreatic Surgery: A Randomized Clinical Trial.

Background: Dexmedetomidine (Dex) may have anti-inflammatory properties and potentially reduce the incidence of postoperative organ injury. Objective: To investigate whether Dex protects pulmonary and renal function via its anti-inflammatory effects in elderly patients undergoing prolonged major hepatobiliary and pancreatic surgery. Design and Setting: Between October 2019 and December 2020, this randomized controlled trial was carried out at a tertiary hospital in Chongqing, China. Patients: 86 patients aged 60-75 who underwent long-duration (> 4 hrs) hepatobiliary and pancreatic surgery without significant comorbidities were enrolled and randomly assigned into two groups at a 1:1 ratio. Interventions: Patients were given either Dex or an equivalent volume of 0.9% saline (Placebo) with a loading dose of 1 µg kg-1 for 10 min, followed by 0.5 µg kg-1 hr-1 for maintenance until the end of surgery. Main Outcome Measures: The changes in serum concentrations of interleukin-6 (IL-6) and tumour necrosis factor-α (TNF-α) were primary outcomes. Results: At one hour postoperatively, serum IL-6 displayed a nine-fold increase (P<0.05) in the Placebo group. Administration of Dex decreased IL-6 to 278.09 ± 45.43 pg/mL (95% CI: 187.75 to 368.43) compared to the Placebo group (P=0.019; 432.16 ± 45.43 pg/mL, 95% CI: 341.82 to 522.50). However, no significant differences in TNF-α were observed between the two groups. The incidence of postoperative acute kidney injury was twice as high in the Placebo group (9.30%) compared to the Dex group (4.65%), and the incidence of postoperative acute lung injury was 23.26% in the Dex group, lower than that in the Placebo group (30.23%), although there was no statistical significance between the two groups. Conclusion: Dex administration in elderly patients undergoing major hepatobiliary and pancreatic surgery reduces inflammation and potentially protects kidneys and lungs. Registration: Chinese Clinical Trials Registry, identifier: ChiCTR1900024162, on 28 June 2019.

The outcomes and biliary complications of a staged biliary reconstruction in living donor liver transplantation: a propensity score matched analysis.

BACKGROUND: Uncontrolled massive bleeding and bowel edema are critical issues during liver transplantation. Temporal intra-abdominal packing with staged biliary reconstruction (SBR) yields acceptable outcomes in deceased donor liver transplantation; however, data on living donor liver transplantation (LDLT) are scarce. METHODS: A retrospective analysis of 1269 patients who underwent LDLT was performed. After one-to-two propensity score matching, patients who underwent LDLT with SBR were compared with those who underwent LDLT with one-stage biliary reconstruction (OSBR). The primary outcomes were graft survival (GS) and overall survival (OS), and the secondary outcomes were postoperative biliary complications. RESULTS: There were 55 and 110 patients in the SBR and OSBR groups, respectively. The median blood loss was 6500 mL in the SBR and 4875 mL in the OSBR group. Patients receiving SBR-LDLT had higher incidence of sepsis (69.0% vs. 43.6%; P < 0.01) and intra-abdominal infections (60.0% vs. 30.9%; P < 0.01). Biliary complication rates (14.5% vs. 19.1%; P = 0.47) and 1-and 5-year GS (87.27%, 74.60% vs. 83.64%, 72.71%; P = 0.98) and OS (89.09%, 78.44% vs. 84.55%, 73.70%; P = 0.752) rates were comparable between the two groups. CONCLUSIONS: SBR could serve as a life-saving procedure for patients undergoing complex critical LDLT, with GS, OS, and biliary outcomes comparable to those of OSBR.

Stent-Graft Placement for Hepatic Arterial Hemorrhage after Pancreaticobiliary Surgery: Long-Term Clinical Outcomes.

PURPOSE: To evaluate the safety and long-term clinical outcomes of stent-graft placement to treat hepatic arterial hemorrhage after pancreaticobiliary surgery. MATERIALS AND METHODS: Outcomes were retrospectively evaluated in 61 patients (50 men and 11 women; mean age, 63 years) who underwent stent-graft placement for delayed arterial hemorrhage (after 24 hours) after pancreaticobiliary surgery from 2006 to 2023. Bleeding sites included the gastroduodenal artery stump (n = 54), common or proper hepatic artery (n = 5), and right hepatic artery (n = 2). The stent-grafts used were Viabahn (n = 27), Comvi (n = 11), Jostent (n = 3), Covera (n = 11), and Lifestream (n = 7). Technical and clinical success and adverse events (AE) were evaluated. After stent-graft placement, overall survival (OS), hemorrhage-free survival (HFS), and stent patency were evaluated. RESULTS: The technical and clinical success rates of stent-graft placement were 97% and 93%, respectively. The severe AE rate was 12% and was significantly higher in patients who underwent pylorus-sacrificing rather than pylorus-preserving surgery (P = .001). None of the severe AEs were associated with patient mortality. Median OS after stent-graft placement was 854 days, and median HFS was 822 days. The 1-, 3-, 5-, and 10-year stent patency rates were 87%, 84%, 79%, and 72%, respectively. CONCLUSIONS: Stent-graft placement was safe and provided long-term control of hepatic arterial hemorrhage after pancreaticobiliary surgery.

Simultaneous total internal biliary diversion during liver transplantation for progressive familial intrahepatic cholestasis type 1: Standard of care?

Patients post liver transplant (LT) with progressive familial intrahepatic cholestasis type 1 (PFIC-1) often develop progressive graft steatohepatitis, intractable diarrhea, and growth failure. A total internal biliary diversion (TIBD) during an LT may prevent or reverse these adverse events. Children with PFIC-1 who underwent an LT at our institute were divided into 2 groups, A and B based on the timeline where we started offering a TIBD in association with LT. Pre-LT parameters, intraoperative details, and posttransplant complications like graft steatosis and diarrhea were also analyzed between the 2 groups, and their growth velocity was measured in the follow-up period. Of 550 pediatric LT performed between 2011 and 2022, 13 children underwent LT for PFIC-1. Group A had 7 patients (A1-A7) and group B had 6 (B1-B6). Patients A1, A4, B4, and B5 had a failed partial internal biliary diversion before offering them an LT. Patients A1, A2, and A6 in group A died in the post-LT period (2 early allograft dysfunction and 1 posttransplant lymphoproliferative disorder) whereas A3, A4, and A5 had graft steatosis in the follow-up period. A4 was offered a TIBD 4 years after LT following which the graft steatosis fully resolved. In group B, B1, B2, B5, and B6 underwent TIBD during LT, and B3 and B4 had it 24 and 5 months subsequently for intractable diarrhea and graft steatosis. None of the patients in group B demonstrated graft steatosis or diarrhea and had good growth catch-up during follow-up. We demonstrate that simultaneous TIBD in patients undergoing LT should be a standard practice as it helps dramatically improve outcomes in PFIC-1 as it prevents graft steatosis and/or fibrosis, diarrhea, and improves growth catch-up.

Contemporary practice and perception of autologous blood salvage in hepato-pancreatico-biliary operations: an international survey.

BACKGROUND: This study aimed to assess contemporary knowledge, attitudes and behaviors around transfusion of intraoperative salvaged blood (sRBCt) during hepato-pancreatico-biliary (HPB) operations. Findings are meant to inform the design of future studies that address provider concerns to change behaviors and improve patient outcomes. METHODS: A survey was designed and assessed for relevance, readability and content, and distributed to an international audience of surgeons performing HPB operations. RESULTS: The 237 respondents were predominantly distributed across North America (37.55%), Europe (27.43%) and Asia (19.83%). Roughly one-half (52.74%) of respondents had used sRBCt in HPB surgery before. Transplantation surgeons were more likely than HPB surgeons to have previously used sRBCt [odds ratio = 5.18 (95% CI 1.89-14.20)]. More respondents believed sRBCt was safe for non-cancer versus cancer operations (68.57% vs. 24.17%, p < 0.0001). Less than half (45.71%) of respondents believed that sRBCt was safe in clean-contaminated fields. Most did not utilize preoperative strategies to avoid donor transfusion. CONCLUSION: Practices related to sRBCt in HPB operations vary widely and there is no consensus on its use. Concerns seem primarily related to cancer-specific and infectious outcomes. While further studies are pursued, surgeons may increase their utilization of preoperative strategies to boost hemoglobin levels for at risk patients.

Prognostic effects of different malignant obstructive jaundice sites on percutaneous biliary intervention: A retrospective controlled study.

Purpose: To compare the survival prognosis of percutaneous transhepatic biliary stenting (PTBS) in the treatment of malignant obstructive jaundice (MOJ) at different horizontal sites. Methods: A total of 120 patients with MOJ who underwent biliary stenting were retrospectively included and analyzed and divided into the high-position group (36 patients), middle-position group (43 patients), and low-position group (41 patients) according to biliary obstruction plane by biliary anatomy. Kaplan-Meier curves were used to test for differences in the overall survival (OS), risk assessment of death and potential risk factors for 1-year survival were analyzed using multifactorial Cox regression. Results: The median survival of the high-, middle-, low-position groups were 16, 8.6, and 5.6 months, with a statistically significant difference (P = 0.017). The 1-year survival rate was 67.6%, 41.9%, and 41.5% in the high-, middle-, low-position groups (P < 0.05), and the 1-year risk of death was 2.35 and 2.93 times higher in the medium- and low-position groups, respectively. The incidences of the main complications were 25%, 48.8%, and 65.9% in the high-, middle-, and low-position groups, respectively, (P = 0.002). While the differences in median stent patency were not statistically significant (P > 0.05) in the groups, alanine transaminase, aspartate transaminase, and total bilirubin levels decreased gradually in each group at 1 month and 3 months after interventional therapy (P < 0.001), while there was no significant difference in the decrease between the groups. Conclusions: Different levels of biliary obstruction in patients with MOJ affect survival, especially at 1 year, where high obstruction treated with PTBS has a low incidence of complications and a low risk of death.

BISCIT: Biliary interventions in critically ill patients with secondary sclerosing cholangitis-a study protocol for a multicenter, randomized, controlled parallel group trial.

BACKGROUND: Progress of cholangitis to cholangiosepsis is a frequent observation in patients with secondary sclerosing cholangitis in critically ill patients (SSC-CIP). Adequate biliary drainage may reduce episodes of cholangiosepsis and therefore stabilize liver function and improve survival. The primary objective of the BISCIT study is to demonstrate that scheduled biliary interventions will reduce incidence of cholangiosepsis, liver transplantation, or death in patients with SSC-CIP. METHODS: A total of 104 patients will be randomized at ten study sites. Patients with SSC-CIP, confirmed by endoscopic retrograde cholangiography (ERC), will be randomized 1:1 either in the intervention group which will be treated with scheduled biliary interventions (i.e., therapeutic ERC) every 8 weeks for 6 months or in the control group which will receive standard of care. The randomization will be stratified by center. The composite primary efficacy endpoint is defined as (1) occurrence of death, (2) necessity of liver transplantation, or (3) occurrence of cholangiosepsis within 6 months following randomization. DISCUSSION: Prospective evaluation of endoscopic treatment procedures is urgently needed to establish an evidence-based therapeutic treatment algorithm in SSC-CIP. A positive trial result could change the current standard of care for patients with SSC-CIP. The results of this study will be disseminated through presentations at international congresses, workshops, and peer-reviewed publications. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov (NCT05396755, date of registration: May 31, 2022, last update: May 31, 2022).

The management of thoracobiliary fistulas in children: a systematic review.

Thoracobiliary fistula (TBF) is a rare condition, in which an atypical communication between the bronchial tree and the biliary tree is present. A comprehensive literature search was conducted on Medline, Embase and Web of Science databases for studies reporting TBF in children. Data regarding patient demographics, site of fistula presentation, preoperative diagnostic procedures needed, and treatment modalities employed were extracted for further analysis. The study pool consisted of 43 studies incorporating 48 cases of TBF. The most frequent symptom was bilioptysis (67%), followed by dyspnea (62.5%), cough (37.5%) and respiratory failure (33%). Regarding the origin of fistula, the left hepatic duct was involved in 29 cases (60.4%), the right hepatic duct in 4 cases (8.3%), and the hepatic junction in 1 case (2%). Surgical management was employed in 46 patients (95.8%). Fistulectomy was performed in 40 patients (86.9%), lung lobectomy or pneumonectomy in 6 (13%), Roux en Y hepaticojejunostomy in 3 (6.5%), and decortication or drainage in 3 cases (6.5%). Three patients died (overall mortality 6.3%), while 17 patients suffered from postoperative complications (overall morbidity 35.4%). TBF in children is a rare but morbid entity which evolves as a result of congenital malformation in the majority of cases. Preoperative imaging of the biliothoracic communication and proper surgical treatment are the components of current management.

Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery.

For recurrent choledocholithiasis, abdominal adhesions in previous surgeries lead to changes in anatomical structures, and a secondary injury occurs easily when performing another operation for laparoscopic common bile duct exploration (LCBDE), which was once considered a relative contraindication. In view of the limitations of the current surgical technique, this study summarized the surgical approaches and crucial anatomical landmarks for reoperation for LCBDE. Four general surgical approaches were proposed to expose the common bile duct, including the ligamentum teres hepatis approach, the anterior hepatic duodenal ligament approach, the right hepatic duodenal ligament approach, and the hybrid approach. Additionally, this study highlighted seven crucial anatomical landmarks: the parietal peritoneum, the gastrointestinal serosa, the ligamentum teres hepatis, the inferior margin of the liver, the gastric antrum, the duodenum, and the hepatic flexure of the colon, which were helpful to safely separate abdominal adhesions and expose the common bile duct. Moreover, to shorten the time of choledocholithotomy, a sequential method was innovatively applied for the removal of the stones in common bile duct. Mastering the above surgical approaches, including identifying crucial anatomical landmarks and adopting the sequential method will improve the safety of reoperation for LCBDE, shorten the operation time, promote the fast recovery of patients, reduce postoperative complications, and contribute to the popularization and application of this technique.

Complications of biliary stenting versus T-tube insertion after common bile duct exploration: A systematic review and meta-analysis.

BACKGROUND: Complications following the insertion T-tube or stent after common bile duct exploration (CBDE) remain problematic in nowadays surgical era. Based on our knowledge, we did not find any meta-analysis intentionally evaluating the complications between both groups. At this moment, we aimed to analyze and compare both procedures' complications, efficacy, efficiency, and feasibility. METHODS: We searched literature from four databases (EuroPMC, PubMed, Scopus, and ClinicalTrials.gov) up to June 2022 to compile the randomized controlled trials and pro-/retrospective cohort studies. Review Manager 5.4 was used to statistically analyze each outcome measured between biliary stenting and T-tube insertion. RESULTS: Sixteen studies with 1,080 patients (534 biliary stents and 546 T-tube) were included for qualitative and quantitative analysis. The pooled risk ratio (RR) of the overall postoperative complications rate was significantly lower in the biliary stent group compared to the T-tube group 0.43 [95% confidence interval (CI) 0.23-0.80, p = 0.007]. In terms of the operation time, length of hospital stay, and readmission rate was also decreased in stenting as biliary drainage over T-tube placement 1.02 minutes [95% CI -1.53, -0.52, p < 0.0001], 1.96 days [95% CI -2.63, -1.29, p < 0.00001], and RR 0.39 [95% CI 0.15-0.97, p = 0.04], respectively. CONCLUSIONS: Stenting as biliary drainage after CBDE was superior to T-tube insertion. A shorter operation time and hospital stay in biliary drainage resulted in a lower overall postoperative complication rate. Other influences, including the complexity and shorter learning curve, might also affect the superiority of biliary stenting.

Clinical Treatment of Perioperative Disseminated Intravascular Coagulation in Patients Who Underwent Gastrointestinal and Hepato-Biliary-Pancreatic Surgery.

BACKGROUND: It is unclear how effective recombinant thrombomodulin (rTM) treatment is in disseminated intravascular coagulation (DIC) during the perioperative period of gastrointestinal and hepato-biliary-pancreatic surgery. The current study aimed to evaluate the therapeutic outcomes of rTM for perioperative DIC. METHODS: We enrolled 100 consecutive patients diagnosed with perioperative DIC after gastrointestinal surgery, and hepato-biliary-pancreatic including emergency procedures, between January 2012 and May 2021. Patients received routine rTM treatment immediately after DIC diagnosis. Then, the DIC, Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were calculated and used for evaluation. The outcomes of rTM treatment and the predictors of survival were evaluated. RESULTS: The causative diseases of DIC were as follows: perforated peritonitis, n = 38; intestinal ischemia, n = 23; intra-abdominal abscess, n = 13; anastomotic leakage, n = 7; pneumonia, n = 7; cholangitis, n = 4; and others, n = 6. The 30-day mortality rate was 18.0%. There were significant differences in the platelet count (13.78 vs 10.41, P = .032) and the SOFA score (5.22 vs 9.89, P<.0001) at the start of DIC treatment between the survivor and non-survivor groups (day 0). The survivor group had a significantly lower DIC score (3.13 vs 4.93, P = .0006) and SOFA score (4.94 vs 12.14, P < .0001) and a higher platelet count (13.50 vs 4.34, P < .0001) than the non-survivor group on day 3. CONCLUSIONS: Comprehensive and systemic treatment is fundamentally essential for DIC, in which rTM may play an important role in the treatment of perioperative DIC.

Hepatic subcapsular hematoma post-endoscopic retrograde cholangiopancreatography requiring embolization.

Endoscopic retrograde cholangiopancreatography (ERCP) placement of biliary stents is the procedure of choice for bile duct strictures. Complications of endoscopic retrograde cholangiopancreatography have a low incidence. Hepatic subcapsular hematoma is uncommon but potentially serious. It is caused by laceration of the bile duct with guidewire or biliary traction during the procedure. Initial management is conservative with supportive measures. In case of hemodynamic instability or superinfection, embolization of the affected branch or even surgery could be performed.

Impact of large amount of intra-abdominal lavage on surveillance of surgical site infection after hepato-pancreato-biliary surgery: A prospective cohort study.

BACKGROUND/PURPOSE: In hepatobiliary and pancreatic (HBP) surgery, the role and significance of intra-abdominal lavage (IAL) for surgical site infection (SSI) is controversial. METHODS: This prospective study was performed between July 2020 and July 2022. A total of 150 patients, 10-L IAL was performed. The lavage fluid at 1-L, 5-L, and 10-L was subjected to bacterial culture examination. Risk factors for SSI were evaluated. RESULTS: Bacterial positivity rate significantly decreased as follows: 1-L, 36% (n = 54); 5-L, 27% (n = 41); 10-L, 23% (n = 35) (36% vs 23%, p = .001). Patients with positive lavage fluid culture at 10-L had significantly higher incidence of both incisional (37% vs 6%, p < .01) and organ/space (54% vs 3%, p < .01) SSI. Multivariate analysis revealed positivity for bacterial culture at 10-L as the strongest independent risk factor for incisional SSI (OR 13.0, 95% CI: 3.86-43.6, p < .01), followed by postoperative pancreatic fistula (OR 11.7, 95% CI: 3.03-45.6, p < .01). Likewise, in organ/space SSI, positivity for bacterial culture at 10-L was the strongest independent risk factor (OR 48.9, 95% CI:12.1-197.7, p < .01), followed by digestive reconstruction (OR 5.20, 95% CI: 1.45-18.6, p = .01). CONCLUSION: IAL decreased the intraperitoneal contamination rate in a volume-dependent manner and can be useful in the surveillance of SSI development in HBP surgery.

Postoperative anastomotic stricture following excision of choledochal cyst: a systematic review and meta-analysis.

PURPOSE: Postoperative anastomotic stricture (PAS) is a well-known complication after correcting choledochal cyst (CC). Although the exact cause of PAS is unknown, various risk factors, such as Todani classification type IV-A, hepaticoduodenostomy, and narrow anastomosis have been reported to be associated with PAS. As far as we know, there is no report with a cumulative analysis of such risk factors of PAS. This systematic review and meta-analysis aimed to investigate the risk factors of PAS following surgical correction of CC in children. METHODS: A systematic literature search for relevant articles was performed in four databases using the combinations of the following terms "Congenital biliary dilatation", "Congenital choledochal cyst", "Choledochal cyst", "Stenosis", "Stricture", and "Complication" for studies published between 1973 and 2022. The relevant cohorts of PAS were systematically searched for clinical presentation and outcomes. RESULTS: The search strategy identified 795 reports. Seventy studies met the defined inclusion criteria, reporting a total of 206 patients with PAS. There is no prospective study in this search. The incidence of PAS was 2.1%. The proportion of Todani classification of the patient with PAS was higher in type IV-A with significant difference (2.0% in type I and 10.1% in type IV-A (p = 0.001)). Fourteen studies reported a comparison between hepaticojejunostomy and hepaticoduodenostomy. There was no significant difference between the two groups (p = 0.36). Four studies reported the diameter of the anastomosis at the primary surgery. The mean diameter was 12.5 mm. Nine studies reported a comparison between laparoscopic surgery and open surgery. Pooled odds ratio of PAS did not show a statistical difference (p = 0.29). CONCLUSIONS: This study suggests that close careful follow-up is important in the patients with type IV-A of CC who underwent excision surgery, considering the possibility of PAS.

[Clinical effect of laparoscopic transcystic drainage combined with common bile duct exploration for the patients with difficult biliary stones].

OBJECTIVE: To explore the feasibility and efficacy of laparoscopic transcystic drainage and common bile duct exploration in the treatment of patients with difficult biliary stones. METHODS: Between April 2020 and December 2021, eighteen patients with difficult biliary stones received laparoscopic transcystic drainage (C-tube technique) and common bile duct exploration. The clinical characteristics and outcomes were retrospectively collected. The safety and effectiveness of laparoscopic transcystic drainage and common bile duct exploration were analyzed. RESULTS: Among the eighteen patients with difficult biliary stones, thirteen patients received traditional laparoscopic transcystic drainage, and the remaining five received modified laparoscopic transcystic drainage. The mean surgical duration were (161±59) min (82-279 min), no bile duct stenosis or residual stone was observed in the patients receiving postoperative cholangiography via C-tube. The maximum volume of C-tube drainage was (500±163) mL/d (180-820 mL/d). Excluding three patients with early dislodgement of C-tube, among the fifteen patients with C-tube maintained, the median time of C-tube removal was 8 d (5-12 d). The duration of hospital stay was (12±3) d (7-21 d) for the 18 patients. Five C-tube related adverse events were observed, all of which occurred in the patients with traditional laparoscopic transcystic drainage, including two abnormal position of the C-tube, and three early dislocation of the C-tube. All the 5 adverse events caused no complications. Only one grade one complication occurred, which was in a patient with modified laparoscopic transcystic drainage. The patient demonstrated transient fever after C-tube removal, but there was no bile in the drainage tube and the subsequent CT examination confirmed no bile leakage. The fever spontaneously relieved with conservative observation, and the patient recovered uneventfully with discharge the next day. All the 18 patients were followed up for 1-20 months (median: 9 months). Normal liver function and no recurrence of stone were detected with ultrasonography or magnetic resonance cholangiopancreatography (MRCP). CONCLUSION: Laparoscopic transcystic drainage combined with common bile duct exploration is safe and feasible in the treatment of patients with difficult biliary stones. The short-term effect is good. Modified laparoscopic transcystic drainage approach may reduce the incidence of C-tube dislocation and bile leak.

Estimation of Physiologic Ability and Surgical Stress (E-PASS) Predicts Postoperative Major Complications After Hepato-Pancreato Biliary Surgery in the Elderly.

BACKGROUND: As society ages, an increasing number of elderly patients require hepato-pancreato-biliary (HPB) surgery. We investigated the risk factors for complications in elderly patients undergoing HPB surgery using surgical risk scoring models. METHODS: We retrospectively investigated 184 elderly patients (≥ 65 years old) who underwent HPB surgery, including the liver, pancreas, bile duct, and/or gallbladder resection, with exemption to simple cholecystectomy between January 2017 and December 2019. The surgical risk scoring models used included the Estimation of Physiological Ability and Surgical Stress (E-PASS), Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), and Geriatric 8 (G8). We evaluated the correlations between the scores and severe complications. Complications were classified as severe (Clavien-Dindo classification [C-D] ≥ III) or non-severe (C-D ≤ II). RESULTS: Complications occurred in 78 patients (24 C-D ≥ III, 54 C-D ≤ II). Preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS) were significantly higher in patients with C-D ≥ IIIa than in those with C-D ≤ II. Multiple logistic regression analysis revealed that PRS (P = 0.01) and SSS (P = 0.04) were independent predictive factors for severe complications. However, the POSSUM and G8 models showed no significant correlations to severe complications. CONCLUSION: E-PASS is a useful model for predicting complications in elderly patients undergoing HPB surgery.

The safety and feasibility of laparoscopic approach for the management of intrahepatic and extrahepatic bile duct stones in patients with prior biliary tract surgical interventions.

The purpose of this study was to compare the efficacy and safety of laparoscopic and open reoperation for intrahepatic and extrahepatic bile duct stones patients with previous biliary tract surgical procedures. The clinical data were retrospectively analyzed of intrahepatic and extrahepatic bile duct stones patients with previous biliary tract surgical procedures who underwent reoperation in the Second General Surgery Department of China Medical University from January 2012 to February 2018. 44 eligible cases were selected. In accordance with the surgical procedures, they were divided into a laparoscopy group (n = 23) and an open surgery group (n = 21). No statistically significant differences were found in the preoperative general clinical data between the two group. Two patients in the laparoscopy group were converted to open surgery. Comparisons between the two groups showed that the intraoperative blood loss [90.87 ± 62.95 (ml) vs. 152.38 ± 118.82 (ml)], the proportion of postoperative analgesia [10/23 (43.5%) vs. 16/21 (76.2%)], and the length of stay [7.19 ± 5.32 (d) vs. 11.00 ± 4.66 (d)] in the laparoscopy group were significantly lower than those in the open surgery group (P < 0.05). Laparoscopic biliary reoperation for intrahepatic and extrahepatic bile duct stones was feasible. Compared with open surgery, laparoscopic surgery has the advantages of less bleeding, a shorter postoperative length of stay, and a lower rate of additional postoperative analgesia.

Long-term outcomes of surgical approaches for bilateral hepatolithiasis: A real-world six-decade experience at a single center.

BACKGROUND: Bilateral hepatolithiasis is an intractable disease and repeated attacks of acute cholangitis seriously threaten patient health. The surgical approaches evolve along with gradually greater understanding of its pathophysiology. METHODS: This is a retrospective cohort study for bilateral hepatolithiasis from January 1958 to December 2018. Before May 1993 (Group A, n = 70), three surgical approaches were adopted: 37 patients with common bile duct exploration (CBDE), 29 with choledochoenterostomy (CE) and four with partial hepatectomy (PH). After June 1993 (Group B, n = 150), 101 patients underwent Oddi sphincter-preserved cholangioplasty with hepatico-subcutaneous stoma (OSPCHS), and 16 with CBDE, 21 with CE, 12 with PH. The perioperative and long-term outcomes were compared. RESULTS: After 1993, the cholangitis recurrence rate significantly decreased from 49.2% to 20.9%, and the stone recurrence rate from 76.3% to 37.1% (both P < .001). Also, the stone-/cholangitis-free durations were prolonged significantly (median: 50.8 vs 26.4/49.6 vs 16.2 months, both P < .001). Preoperative cholangitis was an independent risk factor for stone recurrence (hazard ratio [HR] = 1.863, P = .018), and residual stone for cholangitis recurrence (HR = 2.838, P < .001). OSPCHS and PH were protective surgical approaches for recurrent stone (CBDE: reference; OSPCHS: HR = .469, P = .016, PH: HR = .219, P = .018) and cholangitis (CBDE: reference; OSPCHS: HR = .421, P = .010, PH: HR = .283, P = .093). CONCLUSIONS: For bilateral hepatolithiasis, the management should focus on hepatobiliary lesion eradication and Oddi sphincter function preservation.