Risk factors for central bile duct injury complicating partial liver resection

Classification of left-side hepatolithiasis for laparoscopic middle hepatic vein-guided anatomical hemihepatectomy combined with transhepatic duct lithotomy

BACKGROUND

Laparoscopic middle hepatic vein-guided anatomical hemihepatectomy combined with transhepatic duct lithotomy (MATL) is an approach that can substantially improve stone clearance rates while reducing the rate of postoperative biliary fistula formation, residual stone rates, and rates of recurrence. In this study, we classified left-side hepatolithiasis cases into four subtypes based upon the diseased stone-containing bile duct, the middle hepatic vein, and the right hepatic duct. We then investigated the risk associated with different subtypes and evaluated the safety and efficacy of the MATL procedure.

METHODS

In total, 372 patients who underwent left hemihepatectomy for left intrahepatic bile duct stones were enrolled. Based on the distribution of the stones, the cases could be divided into four types. The risk of surgical treatment was compared for the four types and the safety, short-term efficacy, and long-term efficacy of the MATL procedure in the four types of left intrahepatic bile duct stones were studied.

RESULTS

Type II was found to be the most likely to cause intraoperative bleeding while type III was likely to cause biliary tract damage and type IV was associated with the highest stone recurrence rate. The MATL procedure did not increase the risk of surgery and was found to reduce the rate of bile leakage, residual stones, and stone recurrence.

CONCLUSION

Left-side hepatolithiasis-associated risk classification is feasible and may represent a viable means of improving the safety and feasibility of the MATL procedure.

When should endovascular gastrointestinal anastomosis transection Glissonean pedicle not be used in hepatectomy? A case report

BACKGROUND

The literature on post-hepatectomy bile duct injury (PHBDI) is limited, lacking large sample retrospective studies and high-quality experience summaries. Therefore, we reported a special case of iatrogenic bile duct injury caused by Glissonean pedicle transection with endovascular gastrointestinal anastomosis (endo-GIA) during a right hepatectomy, analyzed the causes of this injury, and summarized the experience with this patient.

CASE SUMMARY

We present the case of a 66-year-old woman with recurrent abdominal pain and cholangitis due to intrahepatic cholangiectasis (Caroli's disease). Preoperative evaluation revealed that the lesion and dilated bile ducts were confined to the right liver, with right hepatic atrophy, left hepatic hypertrophy, and hilar translocation. This problem can be resolved by performing a standard right hepatectomy. Although the operation went well, jaundice occurred soon after the operation. Iatrogenic bile duct injury was considered after magnetic resonance cholangiopancreatography review, and the second operation were performed 10 d later. During the second operation, it was found that the endo-GIA had damaged the lateral wall of the hepatic duct and multiple titanium nails remained in the bile duct wall. This led to severe stenosis of the duct wall, and could not be repaired. Therefore, the injured bile duct was transected, and a hepatic-jejunal-lateral Roux-Y anastomosis was performed at the healthy part of the left hepatic duct. After this surgery, the patient had a smooth postoperative recovery, and the total bilirubin gradually decreased to normal. The patient was discharged 41 d after operation. No anastomotic stenosis was found at the 6 mo of follow-up.

CONCLUSION

Not all cases are suitable for endo-GIA transection of Glissonean pedicle, especially in cases of intrahepatic bile duct lesions. PHBDI caused by endo-GIA is very difficult to repair due to extensive ischemia, which requires special attention.

Imaging Features of Main Posthepatectomy Complications: A Radiologist’s Challenge

In the recent years, the number of liver resections has seen an impressive growth. Usually, hepatic resections remain the treatment of various liver diseases, such as malignant tumors, benign tumors, hydatid disease, and abscesses. Despite technical advancements and tremendous experience in the field of liver resection of specialized centers, there are moderately high rates of postoperative morbidity and mortality, especially in high-risk and older patient populations. Although ultrasonography is usually the first-line imaging examination for postoperative complications, Computed Tomography (CT) is the imaging tool of choice in emergency settings due to its capability to assess the whole body in a few seconds and detect all possible complications. Magnetic resonance cholangiopancreatography (MRCP) is the imaging modality of choice for delineating early postoperative bile duct injuries and ischemic cholangitis that may arise in the late postoperative phase. Moreover, both MDCT and MRCP can precisely detect tumor recurrence. Consequently, radiologists should have knowledge of these surgical procedures for better comprehension of postoperative changes and recognition of the radiological features of various postoperative complications.

Evaluation of bile sterility in patients undergoing liver resection

Introduction: Surgery remains the mainstay of treatment for liver tumors. Significant differences in complication rates between liver surgery centers have been reported ranging from 4.1% up to 47.7%. There have been little papers or studies on the impact of bile infection on postoperative complications in patients undergoing surgery for liver cancer. Aim: The aim of our study was to assess the etiology of bile infections in patients following liver resection and to evaluate its impact on complications and perioperative mortality. Materials and methods: The studied material consisted of 69 patients undergoing surgery for liver tumors at the Department of General and Transplant Surgery of the Medical University of Lodz between 2011 and 2013, when the intraoperative bile cultures were available. Results: The intraoperative bile cultures were positive for bacteria in 12 cases (18.75%), while in other cases the bile was sterile (n = 52). In 41.61% of cases, a methicillin-resistant strain was identified. Two patients presented with jaundice, associated with abdominal pain in one patient; other patients complained of abdominal pain only (jaundice: 16.67%; abdominal pain: 91.67%). In both cases, jaundice was not accompanied by any other typical symptoms of cholangitis; also, palliative surgery was performed in both cases. In patients with confirmed bile infection, jaundice was significantly more common (16.67% vs 0.00%; p = 0.033). Patients with sterile bile cultures reported weight loss significantly more often compared to patients with bile infection (26.90% vs 0.00%; p = 0.042). The hospital stay was longer in patients with bile infection (p = 0.138), whereas the hospitalization was significantly longer in patients infected with methicillin-resistant strains compared to both patients with sterile bile and those with bile infection with non-resistant strains. Conclusions: The causes and real incidence of asymptomatic bile infection remain unknown. Routine bile cultures in patients undergoing liver surgery may prevent complications by early modification of antibiotic regime considering the antibiogram, and identification of the most common causes of asymptomatic bile infection may translate to better preoperative antibiotic prophylaxis.

Analysis of the biliostatic potential of two sealants in a standardized porcine model of liver resection

BACKGROUND

Improved resection techniques has decreased mortality rate following liver resections(LRx). Sealants are known as effective adjuncts for haemostasis after LRx. We compared biliostatic effectiveness of two sealants in a standardized porcine model of LRx.

MATERIAL AND METHODS

We accomplished left hemihepatectomy on 27 pigs. The animals were randomized in control group(n = 9) with no sealant and treatment groups (each n = 9), in which resection surfaces were covered with TachoSil^® and TissuFleece^®/Tissucol Duo^®. After 5 days the volume of ascites(ml), bilioma and/or bile leakages and degree of intra-abdominal adhesions were analysed.

RESULTS

Proportion of ascites was lower in TissuFleece/Tissucol Duo^® group. The ascites volume was lower in TachoSil^® group. In sealant groups, increased adhesion specially in the TachoSil^® group was seen. A reduction of the "bilioma rate" was seen in sealant groups, which was significantly lower in TissuFleece^®/Tissucol Duo^® group.

CONCLUSION

In a standardized condition sealants have a good biliostatic effect but with heterogeneous potentials. This property in combination with the cost-benefit analysis should be the focus of future prospective studies.

Imaging of the postoperative liver: review of normal appearances and common complications

Several benign and malignant liver diseases may require surgical treatment for cure, including anatomical resections based on the segmental anatomy of the liver, non-anatomical (wedge) resections, and surgical management of biliary cysts. The type of surgery depends not only on the location and the nature of the disease, but also on the expertise of the surgeon. Whereas ultrasonography is often the first-line imaging examination in case of suspected postoperative complication, multidetector computed tomography (MDCT) is of greater value for identifying normal findings after surgery, early postoperative pathologic fluid collections and vascular thromboses, and tumor recurrence in patients who have undergone hepatic surgery. Magnetic resonance cholangiopancreatography (MRCP) is the imaging modality of choice for depicting early postoperative bile duct injuries and ischemic cholangitis that may occur in the late postoperative phase. Both MDCT and MRCP can accurately depict tumor recurrence. Radiologists should become familiar with these surgical procedures to better understand postoperative changes, and with the normal imaging appearances of various postoperative complications to better differentiate between complications and normal findings.

Surgical resection after down-staging of locally advanced hepatocellular carcinoma by localized concurrent chemoradiotherapy

BACKGROUND

This study evaluated the down-staging efficacy and impact on resectability of concurrent chemoradiotherapy (CCRT) followed by hepatic arterial infusion chemotherapy (HAIC) in locally advanced hepatocellular carcinoma, and identified prognostic factors of disease-free survival (DFS) and overall survival (OS) after curative resection.

METHODS

DFS and OS were investigated using clinicopathologic variables. Functional residual liver volume (FRLV) was assessed before CCRT and again before surgery in patients with major hepatectomy. Tumor marker response was defined as elevated tumor marker levels at diagnosis but levels below cutoff values before surgery (α-fetoprotein < 20 ng/mL, protein induced by vitamin K absence or antagonist-II < 40 mAU/mL).

RESULTS

Of 243 patients who received CCRT followed by HAIC between 2005 and 2011, 41 (16.9 %) underwent curative resection. Tumor down-staging was demonstrated in 32 (78 %) of the resected patients. FRLV significantly increased from 47.5 to 69.9 % before surgery in patients who underwent major hepatectomy. In addition, the OS of the curative resection group was significantly higher than the OS of the CCRT followed by HAIC alone group (49.6 vs. 9.8 % at 5-year survival; p < 0.001). By multivariate analysis, the poor prognostic factors for DFS after curative resection were tumor marker non-response and the presence of a satellite nodule; however, tumor marker non-response was the only independent poor prognostic factor of OS.

CONCLUSIONS

CCRT followed by HAIC increased resectability by down-staging tumors and increasing FRLV. Curative resection may provide good long-term survival in tumor marker responders who undergo CCRT followed by HAIC.

Hanging manoeuver for a left hepatectomy using Glisson's approach with a focus on tape position in liver hilum

BACKGROUND

Successful use of the hanging manoeuver during a hepatic resection requires the tape to be placed anatomically. The aim of this study is to describe the outcomes after variations in tape placement while using the hanging manoeuver during a left hepatectomy.

METHODS

A whole cohort in whom the hanging manoeuver was attempted for a left hepatectomy from March 2003 to October 2011 was divided chronologically into three groups based on the tape position in the hilum along the ligamentum venosum (LV); conventionally between the right and left Glisson's pedicles (group 1), at the ventral side of the LV (group 2), and at the dorsal side of the LV (group 3). Patient characteristics, operative outcomes and complications defined using Clavien's classification were compared.

RESULTS

A total of 151 patients were enrolled in one of three groups: group 1 (n = 54), group 2 (n = 35), and group 3 (n = 62). The hanging tape was successfully positioned in all patients as planned in the three groups. In group 2 and 3, the hanging manoeuver was continuously applied during a parenchymal transection. The Glisson's pedicle injury during hilar dissection was more common in group 2 (%, 51.4 versus 5.6 in group 1 and 3.2 in group 3; P = 0.001). Group 3 showed a shorter median operative time (min, 151 versus 210 in group 1 and 220 in group 2; P = 0.001), a shorter median hospital stay (days, 7 versus 10 in group 1 and 2; P = 0.012) and a lower complication rate (%, 1.6 versus 13.0 in group 1 and 37.1 in group 2; P = 0.001) without any operative mortality, major morbidity, blood transfusion or reoperation.

CONCLUSIONS

The hanging manoeuver had 100% feasibility with good outcomes during a left hepatectomy. The tape should be positioned to surround the left Glisson's pedicle and LV together as this helps to protect the caudate lobe.

Operative terminology and post-operative management approaches applied to hepatic surgery: Trainee perspectives

Outcomes in hepatic resectional surgery (HRS) have improved as a result of advances in the understanding of hepatic anatomy, improved surgical techniques, and enhanced peri-operative management. Patients are generally cared for in specialist higher-level ward settings with multidisciplinary input during the initial post-operative period, however, greater acceptance and understanding of HRS has meant that care is transferred, usually after 24-48 h, to a standard ward environment. Surgical trainees will be presented with such patients either electively as part of a hepatobiliary firm or whilst covering the service on-call, and it is therefore important to acknowledge the key points in managing HRS patients. Understanding the applied anatomy of the liver is the key to determining the extent of resection to be undertaken. Increasingly, enhanced patient pathways exist in the post-operative setting requiring focus on the delivery of high quality analgesia, careful fluid balance, nutrition and thromboprophlaxis. Complications can occur including liver, renal and respiratory failure, hemorrhage, and sepsis, all of which require prompt recognition and management. We provide an overview of the relevant terminology applied to hepatic surgery, an approach to the post-operative management, and an aid to developing an awareness of complications so as to facilitate better confidence in this complex subgroup of general surgical patients.

Bile duct leaks from the intrahepatic biliary tree: a review of its etiology, incidence, and management

Bile leaks from the intrahepatic biliary tree are an important cause of morbidity following hepatic surgery and trauma. Despite reduction in mortality for hepatic surgery in the last 2 decades, bile leaks rates have not changed significantly. In addition to posted operative bile leaks, leaks may occur following drainage of liver abscess and tumor ablation. Most bile leaks from the intrahepatic biliary tree are transient and managed conservatively by drainage alone or endoscopic biliary decompression. Selected cases may require reoperation and enteric drainage or liver resection for management.