Impact of post-hepatectomy biliary leaks on long-term survival in different liver tumors: A single institute experience.

Backgrounds/Aims: A postoperative biliary leak is one of the most morbid complications occurring after a liver resection, the long-term impact of which remains unknown. Methods: Retrospective analysis of consecutive liver resections performed from 1 January 2011 to 31 December 2021. Primary endpoint of disease-free survival (DFS) was compared between patients with and without a bile leak, stratifying for tumor type. Survival curves were plotted using Kaplan-Meier estimates, and differences between them were analyzed using the log-rank test. Results: In toto, 862 patients were analyzed, and included 306 (35.5%) hepatocellular carcinomas, 212 (24.6%) metastatic colorectal cancers, and 111 (12.9%) cholangiocarcinomas (69 intrahepatic cholangiocarcinomas, 42 hilar cholangiocarcinomas). Occurrence of a bile leak was associated with significantly poorer DFS only in patients with cholangiocarcinoma (median DFS 9.9 months vs. 24.9 months, p = 0.013), and further analysis was restricted to this cohort. A Cox regression performed for factors associated with DFS detriment in patients with cholangiocarcinoma showed that apart from node positivity (hazard ratio [HR]: 2.482, p = 0.033) and margin positivity (HR: 2.65, p = 0.021), development of a bile leak was independently associated with worsening DFS on both univariate and multiple regression analyses (HR: 1.896, p = 0.033). Conclusions: Post-hepatectomy biliary leaks are associated with significantly poorer DFS only in patients with cholangiocarcinoma, but not in patients with hepatocellular carcinoma or metastatic colorectal cancer. Methods to mitigate this survival detriment need to be explored.

Post-operative complications of cholecystectomy: what the radiologist needs to know.

Cholecystectomy is one of the most performed surgical procedures. The safety of this surgery notwithstanding, the sheer volume of operations results in a notable incidence of post-cholecystectomy complications. Early and accurate diagnosis of such complications is essential for timely and effective management. Imaging techniques are critical for this purpose, aiding in distinguishing between expected postsurgical changes and true complications. This review highlights current knowledge on the indications for cholecystectomy, pertinent surgical anatomy and surgical technique, and the recognition of anatomical variants that may complicate surgery. The article also outlines the roles of various imaging modalities in identifying complications, the spectrum of possible postsurgical anatomical changes, and the implications of such findings. Furthermore, we explore the array of complications that can arise post-cholecystectomy, such as biliary system injuries, gallstone-related issues, vascular complications, and the formation of postsurgical collections. Radiologists should be adept at identifying normal and abnormal postoperative findings to guide patient management effectively.

Treatment Strategies for Bile Leak Following Pediatric Liver Transplantation.

There are no standard management protocols for the treatment of bile leak (BL) after liver transplantation. The objective of this study is to describe treatment options for BL after pediatric LT. METHODS: Retrospective analysis (January 2010-March 2023). VARIABLES STUDIED: preoperative data, status at diagnosis, and postoperative outcome. Four groups: observation (n = 9), percutaneous transhepatic cholangiography (PTC, n = 38), ERCP (2), and surgery (n = 27). RESULTS: Nine hundred and thirty-one pediatric liver transplantation (859 LDLT and 72 DDT); 78 (8.3%) patients had BL, all in LDLT. The median (IQR) peritoneal bilirubin (PB) level and fluid-to-serum bilirubin ratio (FSBR) at diagnosis was 14.40 mg/dL (8.5-29), and 10.7 (4.1-23.7). Patients who required surgery for treatment underwent the procedure earlier, at a median of 14 days (IQR: 7-19) versus 22 days for PTC (IQR: 15-27, p = 0.002). PB and FSBR were significantly lower in the observation group. In 11 cases, conservative management had resolution of the BL in an average time of 35 days, and 38 patients underwent PTC in a median time of 22 days (15-27). Twenty-seven (34.6%) patients were reoperated as initial treatment for BL in a median time of 17 days (1-108 days); 25 (33%) patients evolved with biliary stricture, 5 (18.5%) after surgery, and 20 (52.6%) after PTC (p = 0.01). CONCLUSION: Patients with BL who were observed presented significantly lower levels of PB and FSBR versus those who underwent PTC or surgery. Patients treated with PTC presented higher rates of biliary stricture during the follow-up.

Chyle and Bile Leak Following Open Cholecystectomy: A Rare Complication.

Gallstone disease is extremely common and frequently and safely treated by cholecystectomy. Chyle leak is a rare but significant side effect of many abdominal surgeries with rarely reported post-cholecystectomy. In this case, we report a 78-year-old lady with multiple comorbidities and symptomatic gallstones who underwent open cholecystectomy complicated by bile and chyle leak, which was successfully managed with endoscopic retrograde cholangiopancreatography (ERCP) and stenting for bile leak and conservative management for the chyle leak, which included drainage, low-fat diet, and octreotide.

A Case of Postoperative Biliary Leak in a Patient With Duplicated Cystic Ducts.

Duplicated cystic ducts are a rare congenital malformation with less than 20 reported cases before 2019. This malformation is important to identify to reduce the risk of intraoperative complications such as bile duct injuries that can increase postoperative morbidity and mortality. We present the case of a 62-year-old male with duplicated cystic ducts that were ligated during laparoscopic cholecystectomy and subsequently complicated by postoperative biloma formation. Treatment options for biliary leak include endoscopic retrograde cholangiopancreatography (ERCP) with stenting, percutaneous drainage, and duct embolization. Each carries the risk of complications such as infection, duct perforation, and stent/drain displacement. Roux-en-Y hepaticojejunostomy (RHYJ) tends to be the last resort when other minimally invasive procedures fail. It is imperative to identify postoperative complications related to cystic duct anomalies and the various treatment options available should these complications occur.

Continuous versus interrupted anastomotic technique for the hepaticojejunostomy: a prospective cohort study.

Background: Interrupted sutures is the gold standard technique of hepaticojejunostomy (HJ) for bilioenteric anastomosis. This study compares the safety and early complications of continuous and interrupted suture HJ. Methods: A prospective study involving all elective HJ between September 2019 and June 2021 was conducted. Patients with type IV or V biliary strictures, duct diameter less than 8 mm and/or associated vascular injury, and bilateral HJ were excluded. The study patients were divided into two random groups; interrupted and continuous anastomotic technique. Patient demographics, preoperative parameters including pathology (benign vs. malignant), HJ leak, suture time, and postoperative morbidity were recorded. Results: Total 34 patients were enroled. Eighteen (52.9%) were into interrupted and 16 (47.1%) patients into the continuous group. Both the groups were comparable with regards to demographics, haemoglobin, serum albumin, preoperative cholangitis and biliary stenting. Total three (8.8%) patients in the entire study developed bile leak; interrupted-2 and continuous-1, which was not significant statistically (P=1.0). Similarly, total number of sutures used and the mean operating time to complete anastomosis in the continuous group was significantly lesser than the interrupted group (2.3±0.5 versus 9.6±1.6, P<0.001) and (16.2±3.1 versus 38.6±9.2 min, P<0.001), respectively. There were three (18.8%) re-exploration in the continuous anastomotic technique. Among them, only one re-operation was due to HJ anastomosis failure without mortality, remaining had re-exploration for bleeding (non-HJ). Conclusions: Both the techniques is safe with comparable morbidity. Further, continuous has an added advantage of decreased anastomotic time and cost.

A rare case of bile leak due to type 2 duct of Luschka injury post open cholecystectomy: a case report.

Bile leak is an uncommon complication post cholecystectomy. The bile may originate from the cystic duct stump and less commonly from the aberrant ducts of Luschka. Such complications may occur when anatomical variations in the biliary tree go unnoticed. This case report presents a 24-year-old otherwise healthy female who presented with abdominal pain and distension that began 3 days after she underwent open cholecystectomy for symptomatic cholelithiasis. Imaging revealed choledocholelithiasis in the distal common bile duct, and free intrabdominal fluid collection. Endoscopic retrograde cholangiopancreatography done showed contrast leak from the duct of Luschka to the gall bladder bed. The biliary tree has many anatomic variations. These variations have clinical significance for surgical treatment of patients with biliary pathology. Surgeons should be aware of such variations to decrease the risk of bile leak post cholecystectomy.

Biliary complications after adult-to-adult living-donor liver transplantation: An international multicenter study of 3633 cases.

In living-donor liver transplantation, biliary complications including bile leaks and biliary anastomotic strictures remain significant challenges, with incidences varying across different centers. This multicentric retrospective study (2016-2020) included 3633 adult patients from 18 centers and aimed to identify risk factors for these biliary complications and their impact on patient survival. Incidences of bile leaks and biliary strictures were 11.4% and 20.6%, respectively. Key risk factors for bile leaks included multiple bile duct anastomoses (odds ratio, [OR] 1.8), Roux-en-Y hepaticojejunostomy (OR, 1.4), and a history of major abdominal surgery (OR, 1.4). For biliary anastomotic strictures, risk factors were ABO incompatibility (OR, 1.4), blood loss >1 L (OR, 1.4), and previous abdominal surgery (OR, 1.7). Patients experiencing biliary complications had extended hospital stays, increased incidence of major complications, and higher comprehensive complication index scores. The impact on graft survival became evident after accounting for immortal time bias using time-dependent covariate survival analysis. Bile leaks and biliary anastomotic strictures were associated with adjusted hazard ratios of 1.7 and 1.8 for graft survival, respectively. The study underscores the importance of minimizing these risks through careful donor selection and preoperative planning, as biliary complications significantly affect graft survival, despite the availability of effective treatments.

Impact of open hepatectomy on postoperative bile leakage in patients with biliary tract cancer.

BACKGROUND: Bile leakage is a common and serious complication of open hepatectomy for the treatment of biliary tract cancer. AIM: To evaluate the incidence, risk factors, and management of bile leakage after open hepatectomy in patients with biliary tract cancer. METHODS: We retrospectively analyzed 120 patients who underwent open hepatectomy for biliary tract cancer from February 2018 to February 2023. Bile leak was defined as bile drainage from the surgical site or drain or the presence of a biloma on imaging. The incidence, severity, timing, location, and treatment of the bile leaks were recorded. The risk factors for bile leakage were analyzed using univariate and multivariate logistic regression analyses. RESULTS: The incidence of bile leak was 16.7% (20/120), and most cases were grade A (75%, 15/20) according to the International Study Group of Liver Surgery classification. The median time of onset was 5 d (range, 1-14 d), and the median duration was 7 d (range, 2-28 d). The most common location of bile leakage was the cut surface of the liver (70%, 14/20), followed by the anastomosis site (25%, 5/20) and the cystic duct stump (5%, 1/20). Most bile leaks were treated conservatively with drainage, antibiotics, and nutritional support (85%, 17/20), whereas some required endoscopic retrograde cholangiopancreatography with stenting (10%, 2/20) or percutaneous transhepatic cholangiography with drainage (5%, 1/20). Risk factors for bile leakage include male sex, hepatocellular carcinoma, major hepatectomy, blood loss, and blood transfusion. CONCLUSION: Bile leakage is a frequent complication of open hepatectomy for biliary tract cancer. However, most cases are mild and can be conservatively managed. Male sex, hepatocellular carcinoma, major hepatectomy, blood loss, and blood transfusion were associated with an increased risk of bile leak.

Outcome of forgotten biliary stents for more than five years-A two-decade experience.

BACKGROUND AND OBJECTIVES: Prolonged biliary stenting may lead to complications such as cholangitis, stentolith and stent migration. There is limited data on forgotten biliary stents for more than five years in literature. The aim of this retrospective study was to analyze the complications and outcomes in patients who forgot to get their biliary stents removed or exchanged for more than five years. METHODS: The study population included patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and plastic biliary stent placements in a tertiary care center from 1990 to 2022 for benign biliary diseases. Loss to follow-up and subsequent forgotten stent for more than five years were observed in 40 patients who underwent ERCP during this study period. We retrospectively analyzed the indications of stenting, present status of stent, complications and outcomes in the study patients. RESULTS: The mean age of the study patients was 51.5 ± 11.5 years with 27 females. Indications of biliary stent placement were choledocholithiasis (33, 82.5%), bile leak (3, 7.5%), benign biliary stricture (2, 5%) and choledochal cyst (2, 5%). The mean duration of forgotten stent was 5.9 ± 3.6 years. Presenting symptoms were abdominal pain (37, 92.5%), fever (26, 65%) and jaundice (32, 80%). Most commonly placed stent was 7 French double pigtail of 10 cm length. Complications in the study patients were cholangitis (35, 87.5%), internal migration (2, 5%), pancreatitis (1, 2.5%) and portal hypertension (1, 2.5%). The outcomes were stone removal (30, 90.9%), stent removal (31, 77.5%), stent reinsertion (19, 47.5%), broken stent (3, 7.5%) and surgery (2, 5%). CONCLUSIONS: Prolonged duration (> 5 years) of forgotten stent is uncommon and is observed most commonly in patients with choledocholithiasis. The most common complication of long duration of forgotten stents was cholangitis followed by internal migration, pancreatitis and portal hypertension. Stone and stent removal was successful in a majority of patents, while surgery was required in less number of patients.

Perioperative strategies for patients undergoing subtotal cholecystectomy: a single-center retrospective review of 102 procedures.

BACKGROUND: Calculous gall bladder disease is often handled by laparoscopic cholecystectomy. In cases where a safe dissection of the hepatocystic triangle cannot be carried out, a subtotal cholecystectomy (STC) may be performed. The perioperative management of patients undergoing STC is characterized by limited evidence. This large single-center series explores some of the perioperative aspects and outcomes after STC. MATERIALS AND METHODS: The study population includes all patients who underwent STC at Oslo University Hospital (Ullevål and Aker Hospitals) from 01.01.2014 to 30.09.2020. A STC was defined as a cholecystectomy where there was a failure to control the cystic duct during surgery. Study variables included demographic data, comorbidities, previous biliopancreatic disease, indication for surgery, perioperative information, subsequent interventions and outcome data. RESULTS: During the study period, 2376 cholecystectomies were performed, and 102 (4.3%) were categorized as STC. Of all patients with STC, 48 (47.1%) had an intra- or postoperative ERCP during the index hospital admission. The indication for ERCP was bile leak in 37 (42.6%) of the cases. The bile leak resolution rate was 60.0 % in intraoperative ERCP vs 95.7% in postoperative ERCP. Among the STC patients, there were no injuries to the central bile ducts. Later, one patient has undergone a remnant cholecystectomy, following fenestrating STC. CONCLUSION: STC was a safe bailout strategy for dissection in the hepatocystic triangle in difficult cholecystectomies. Intraoperative ERCP increased procedure time and was associated with a lower rate of leak resolution, as compared to postoperative ERCP.

Dual Lumen Microcatheter in Percutaneous Biliary Drainage for Postoperative Bile Leakage: A Case Report.

Percutaneous biliary intervention is widely accepted as an effective and safe treatment for various types of bile duct diseases. We present the case of a 44-year-old woman who developed bile leakage after a living-donor liver transplantation for locally advanced cholangiocarcinoma. A percutaneous drainage tube was placed in the segment 8 bile duct via the blind end of the jejunum. However, the bile leakage was unchanged. Bile leakage from the right posterior hepatic duct was suspected. Using a dual lumen microcatheter, a percutaneous drainage tube was placed in the segment 7 bile duct via the blind end of the jejunum, which reduced the bile leakage. These results suggest that a dual lumen microcatheter is a valuable tool for navigating the biliary tree during difficult percutaneous biliary interventions.

Uncommon Complication of a Biliary Leak After Adjustable Gastric Band Removal: A Case Report.

In the context of adjustable gastric band (AGB) placements and the prevalent issue of weight regain with associated complications, revision surgery for gastric bands becomes imperative. Such revisions may encompass band removal or conversion to bariatric procedures, often accompanied by an escalated risk profile, potentially contributing to a 20% morbidity rate. Laparoscopic sleeve gastrectomy (LSG) has gained prominence due to its technical simplicity, effectiveness in weight loss, and lower complication rates. Specific cases involving LSG post-AGB complications are associated with staple line disruptions and leaks. This case report describes a rare complication in a 59-year-old patient following AGB removal and subsequent laparoscopic sleeve gastrectomy. The complication emerged six hours after the surgery, with approximately 400 cc of bile material reported in the drainage. A laparoscopic reintervention was conducted, revealing bile leakage from the second Couinaud hepatic segment. Successful management of the leakage was achieved through simple hepatic suturing using non-absorbable monofilament. Within 24 hours, no further leakage occurred, and the patient was discharged without additional complications. Our case also demonstrates how complex it can be to switch between different medical procedures, and it emphasizes the need for careful planning and precise surgery in the evolving world of bariatric medicine. It is worth noting that there is a dearth of literature addressing this specific complication. Consequently, this study has the potential to provide valuable insights for surgeons who may encounter a similar scenario in their clinical practice.

Laparoscopic Cholecystectomy Versus Open Cholecystectomy in Acute Cholecystitis: A Literature Review.

Cholecystectomy is a common surgical procedure performed worldwide for acute cholecystitis. Acute cholecystitis occurs when the cystic duct is obstructed by a gallstone, which causes gallbladder distension and subsequent inflammation of the gallbladder. Acute cholecystitis is characterized by pain in the right upper quadrant, anorexia, nausea, fever, and vomiting. Cholecystectomy is the treatment of choice for acute cholecystitis. The two commonly performed types of cholecystectomies are open cholecystectomy and laparoscopic cholecystectomy. However, the approach of choice widely fluctuates with regard to various factors such as patient history and surgeon preference. It is imperative to understand the variations in outcomes of different approaches and how best they fit an individual patient when deciding the technique to be undertaken. This article reviews several studies and compares the two techniques in terms of procedure, mortality rate, complication rate, bile leak/injury rate, conversion rate, and bleeding rate.

Usefulness of Intraductal Placement of a Dumbbell-Shaped Fully Covered Self-Expandable Metal Stent for Post-Cholecystectomy Bile Leaks.

Background and aims: In the treatment of post-cholecystectomy bile leaks, endoscopic naso-biliary drainage (ENBD) or biliary stenting using plastic stents is the standard of care. Fully covered self-expandable metal stent (FCSEMS) placement across the sphincter of Oddi is considered a salvage therapy for refractory cases, but pancreatitis and migration are the major concerns. Intraductal placement of a dumbbell-shaped FCSEMS (D-SEMS) could avoid these drawbacks of FCMSESs. In this retrospective study, we investigated the usefulness of intraductal placement of the D-SEMS for post-cholecystectomy bile leaks. Methods: Six patients who underwent intraductal placement of the D-SEMS for post-cholecystectomy bile leaks were enrolled. This method was performed as initial treatment in three patients and as salvage treatment in three ENBD refractory cases. Results: Technical and clinical successes were obtained in 6 (100%) patients and 5 (83%) patients, respectively. One clinically unsuccessful patient required laparoscopic peritoneal lavage. The early adverse event was one case of mild pancreatitis (17%). The median duration of the D-SEMS indwelling was 61 days (42-606 days) with no migration cases, all of which were successfully removed. The median follow-up after index ERCP was 761 (range: 161-1392) days with no cases of recurrent bile leaks. Conclusions: Intraductal placement of the D-SEMS for post-cholecystectomy bile leaks might be safe and effective even in refractory cases.

Laparoscopic cholecystectomy: post-operative bile and chyle leaks. A case report.

One week after an elective laparoscopic cholecystectomy at an outside hospital, a 56-year-old male presented to the emergency department with right-sided abdominal pain. Computerized tomography (CT) revealed a complex fluid collection in the gallbladder fossa. The patient underwent drain placement and received broad-spectrum intravenous antibiotics. Drain output was suspicious for a chyle leak, which was confirmed by elevated fluid triglyceride levels. Magnetic resonance cholangiopancreatography (MRCP) and hepatobiliary iminodiacetic acid (HIDA) analysis showed evidence of a concurrent bile leak. After starting a low fat, high protein diet and octreotide, a common bile duct sphincterotomy with plastic stent placement was performed. The patient's symptoms and drain output proceeded to improve. The cause of the chyle leak is unclear. However, with consideration of the patient's concurrent bile leak, an injury to the right major lymphatic drainage pathway and adjacent bile duct is suspected.

Comparative analysis of surgical management approaches for hydatid liver cysts: conventional vs. minimally invasive techniques.

INTRODUCTION: Hydatid liver disease is a prevalent condition in endemic areas, particularly in the Middle East and North Africa. The use of laparoscopy as a treatment option has gained popularity. However, there is still ongoing debate regarding the optimal approach for surgical management. In this study, we present our experience with the surgical treatment of hydatid liver disease comparing conventional and minimally invasive approaches, including laparoscopic and robotic options. METHODS: We conducted a retrospective review of patients who underwent surgery for hydatid liver disease at our institution. Data was collected on the patients' clinical presentations, cyst characteristics, surgical procedures performed, intraoperative findings, and postoperative complications. RESULTS: A total of 98 hydatid liver cysts were surgically managed in 57 patients. The mean age of the patients was 37.2 ± 10.2 years, with 38 (66.7%) being male. Among the patients, 14 (24.6%) underwent conventional surgery (6 partial pericystectomy, 4 total pericystectomy, and 4 liver resection), 37 (64.9%) underwent laparoscopic surgery (31 partial pericystectomy, 4 total pericystectomy, and 2 liver resection), and 6 (10.5%) underwent robotic surgery (6 partial pericystectomy). There were no significant differences between the conventional surgery and minimally invasive groups in terms of patient age, gender, cyst size, or number. However, laparotomy was associated with a higher number of total pericystectomy and liver resection procedures compared to the minimally invasive approach (P = 0.010). Nonetheless, the operation time and blood loss were comparable between both groups. Perioperative complications occurred in 19 (33.3%) patients, with 16 (84%) experiencing minor issues. Bile leak occurred in 8 (14%) patients, resolving spontaneously in 5 patients. There was no significant difference (P = 0.314) in the incidence of complications between the two groups. Conventional surgery, however, was associated with a significantly longer hospital stay (P = 0.034). During follow-up, there were no cases of mortality or cyst recurrence in our cohort. CONCLUSION: Minimally invasive approaches for hydatid liver cysts offer advantages such as shorter hospitalization and potentially quicker recovery, making them valuable treatment options when accompanied by careful patient selection and adherence to proper surgical techniques.

Unveiling the Hidden Culprit: A Case of Bile Leakage Post-Cholecystectomy Caused by a Luschka Duct.

Teaching Point: Recognize anatomical bile duct anomalies as a potential etiology of bile leakage post-cholecystectomy, and emphasize the importance of adequate radiological evaluation for correct management.

Massive Hemothorax Caused by Removal of Percutaneous Transhepatic Abscess Drainage Tube for Bile Leak After Subtotal Cholecystectomy: A Case Report.

A 59-year-old man with a past medical history of gallstones was diagnosed with acute cholecystitis and received antibiotic treatment. He was discharged after ten days of hospitalization and was due to undergo laparoscopic cholecystectomy. Three months later, however, he had to be readmitted due to a recurrence of acute cholecystitis. Subsequently, laparoscopic reconstituting subtotal cholecystectomy was performed because Inflammation of the gallbladder was severe. At the first postoperative outpatient visit, the patient reported obstructive jaundice, and computed tomography (CT) scan revealed fluid collection in the hepatic bed and a missed common bile duct stone. Percutaneous transhepatic abscess drainage (PTAD) was performed on admission, and endoscopic stone removal was attempted the following day but was challenging due to a periampullary diverticulum. During laparotomy for stone extraction, the patient experienced prolonged shock and CT showed bleeding from the liver and massive right hemothorax. After open chest drainage and hemostasis, transcatheter arterial embolization (TAE) was performed. Such a case has never been reported before, and the PTAD tube should be handled cautiously.

Immediate and Late Complications After Liver Transplantation.

Other than rejection, hepatic artery and portal vein thrombosis are the most common complications in the immediate postoperative period with hepatic arterial thrombosis more common and more devastating. Hepatic artery stenosis is more common 1 month after transplantation, whereas portal and hepatic vein stenosis is more often seen as a late complication. Ultrasound is the first-line imaging examination to diagnose vascular complications with contrast-enhanced CT useful if ultrasound findings are equivocal. MR cholangiography is often most helpful in diagnosing bile leaks, biliary strictures, and biliary stones.