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Obata T, Matsumoto K, Harada K, Hattori N, Sato R, Matsumi A, Miyamoto K, Terasawa H, Fujii Y, Uchida D, Horiguchi S, Tsutsumi K, Otsuka M. Endoscopic Bridging Stent Placement Improves Bile Leaks After Hepatic Surgery. J Clin Med 2025; 14:3381. [PMID: 40429376 PMCID: PMC12112124 DOI: 10.3390/jcm14103381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2025] [Revised: 05/05/2025] [Accepted: 05/09/2025] [Indexed: 05/29/2025] Open
Abstract
Background: Endoscopic treatment is one of the first-line treatments for bile leaks after hepatic surgery. However, detailed reports of endoscopic treatment for bile leaks after hepatic resection (HR) or liver transplantation (LT) are scarce. The outcomes of endoscopic treatment for bile leaks after hepatic surgery were examined, and factors related to successful treatment were identified. Methods: A total of 122 patients underwent endoscopic treatment for bile leaks after hepatic surgery. The diagnosis of a bile leak is based on the ISGLS criteria. The decision to perform endoscopic retrograde cholangiography (ERC) is made based on the amount of drainage output, laboratory data, clinical symptoms, and CT scan findings. In our study, the site of the bile leak was assessed using ERC. Endoscopic stents were placed to bridge across the bile leak site as much as possible. Otherwise, stents were placed near the leak site. Endoscopic stents were replaced every 2-3 months until an improvement in the bile leak was observed with or without biliary strictures. The outcomes of endoscopic treatment and the factors related to clinical success were evaluated. Results: Seventy-four patients with HR and forty-eight patients with LT were treated endoscopically. Technical and clinical success was achieved in 89% (109/122) and 82% (100/122) of patients, respectively. Three (2%) patients died from uncontrollable bile leaks. Bridging stent placement (p < 0.001), coexistent percutaneous drainage (p = 0.0025), and leak severity (p = 0.015) were identified as independent factors related to the clinical success of endoscopic treatment. During a median observation period of 1162 days after the achievement of clinical success, bile leak recurrence was observed in only three cases (3%). Conclusions: Endoscopic treatment is safe and effective for bile leaks after hepatic surgery. Bridging stent placement across the leak site is the most crucial factor for clinical success.
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Affiliation(s)
| | - Kazuyuki Matsumoto
- Department of Gastroenterology and Hepatology, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama 700-8558, Japan; (T.O.); (K.H.); (N.H.); (R.S.); (A.M.); (K.M.); (H.T.); (Y.F.); (D.U.); (S.H.); (K.T.); (M.O.)
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Chen DX, Fang KX, Chen SX, Hou SL, Wen GH, Yang HK, Shi DP, Lu QX, Zhai YQ, Li MY. Optimal timing of endoscopic biliary drainage for bile duct leaks: A multicenter, retrospective, clinical study. World J Gastrointest Surg 2025; 17:99425. [PMID: 40162415 PMCID: PMC11948142 DOI: 10.4240/wjgs.v17.i3.99425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 01/14/2025] [Accepted: 02/05/2025] [Indexed: 02/24/2025] Open
Abstract
BACKGROUND Bile duct leaks (BDLs) are serious postsurgical adverse events. Typically, conservative management with abdominal drainage is the initial treatment option. However, prolonged abdominal drainage without improvement can lead to biliary stricture and delay the optimal timing of endoscopic retrograde cholangiopancreatography (ERCP). AIM To identify the optimal timing for ERCP and the period during which clinical observation with conservative management is acceptable, balancing ERCP success and the risk of biliary strictures. METHODS We conducted a multicenter retrospective study involving 448 patients with BDLs between November 2002 and November 2022. The patients were divided into four groups based on the timing of ERCP: 3 days, 7 days, 14 days, and 21 days. The primary outcome was clinical success, defined as the resolution of BDL and related symptoms within 6 months without additional percutaneous drainage, surgery, or death. The secondary outcome was incidence of biliary strictures. Univariate and multivariate logistic regression analyses were performed to identify factors associated with ERCP success and biliary stricture occurrence. RESULTS In a cohort of 448 consecutive patients diagnosed with BDLs, 354 were excluded, leaving 94 patients who underwent ERCP. Clinical success was achieved in 84% of cases (79/94), with a median ERCP timing of 20 days (9.5-35.3 days). Biliary strictures were identified in 29 (30.9%) patients. Performing ERCP within 3 weeks, compared to after 3 weeks, was associated with higher success rates [92.0% (46/50) vs 75.0% (33/44), P = 0.032] and a lower incidence of biliary stricture incidence [18.0% (9/50) vs 45.5% (20/44), P = 0.005]. Subsequent multivariate analysis confirmed the association with higher success rates (odds ratio = 4.168, P = 0.045) and lower biliary stricture rates (odds ratio = 0.256, P = 0.007). CONCLUSION Performing ERCP for BDLs within 3 weeks may be associated with a higher success rate and a lower biliary stricture rate. If patients with BDLs do not respond to conservative treatment, ERCP is suggested to be performed within 3 weeks.
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Affiliation(s)
- De-Xin Chen
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
- Graduate School, Chinese PLA General Hospital, Beijing 100853, China
| | - Kai-Xuan Fang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
- Graduate School, Chinese PLA General Hospital, Beijing 100853, China
- Department of Gastroenterology and Hepatology, The 960th Hospital of PLA, Jinan 050035, Shandong Province, China
| | - Sheng-Xin Chen
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Sen-Lin Hou
- Department of Gastroenterology and Hepatology, The Second Hospital of Hebei Medical University, Hebei 050035, China
| | - Gui-Hai Wen
- Department of Gastroenterology and Hepatology, Handan Central Hospital, Hebei 056001, China
| | - Hai-Kun Yang
- Department of Gastroenterology and Hepatology, Shanxi Provincial People’s Hospital, Shanxi 030012, China
| | - Da-Peng Shi
- Department of Gastroenterology and Hepatology, First Affiliated Hospital of Army Medical University of PLA, Chongqing 400042, China
| | - Qing-Xin Lu
- Department of Gastroenterology and Hepatology, Second Affiliated Hospital of Army Medical University of PLA, Chongqing 400042, China
| | - Ya-Qi Zhai
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Ming-Yang Li
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing 100853, China
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Gon H, Komatsu S, Soyama H, Tanaka M, Fukushima K, Urade T, So S, Yoshida T, Arai K, Ishida J, Nanno Y, Tsugawa D, Yanagimoto H, Toyama H, Kido M, Fukumoto T. Impact of bile leak on the prognosis of patients with hepatocellular carcinoma who have undergone liver resection. Langenbecks Arch Surg 2024; 409:233. [PMID: 39078441 DOI: 10.1007/s00423-024-03430-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Accepted: 07/23/2024] [Indexed: 07/31/2024]
Abstract
PURPOSE The impact of postoperative bile leak on the prognosis of patients with hepatocellular carcinoma who underwent liver resection is controversial. This study aimed to investigate the prognostic impact of bile leak for patients with hepatocellular carcinoma who underwent liver resection. METHODS Patients with hepatocellular carcinoma who underwent liver resection between 2009 and 2019 at Kobe University Hospital and Hyogo Cancer Center were included. After propensity score matching between the bile leak and no bile leak groups, differences in 5-year recurrence-free and overall survival rates were evaluated using the Kaplan-Meier method. RESULTS A total of 781 patients, including 43 with postoperative bile leak, were analyzed. In the matched cohort, 40 patients were included in each group. The 5-year recurrence-free survival rates after liver resection were 35% and 32% for the bile leak and no bile leak groups, respectively (P = 0.857). The 5-year overall survival rates were 44% and 54% for the bile leak and no bile leak groups, respectively (P = 0.216). CONCLUSION Overall, bile leak may not have a profound negative impact on the prognosis of patients with hepatocellular carcinoma who have undergone liver resection.
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Affiliation(s)
- Hidetoshi Gon
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Shohei Komatsu
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Hirotoshi Soyama
- Department of Surgery, Hyogo Cancer Center, 13-70 Kitaoji-cho, Akashi, 673-8558, Japan
| | - Motofumi Tanaka
- Department of Surgery, Hyogo Cancer Center, 13-70 Kitaoji-cho, Akashi, 673-8558, Japan
| | - Kenji Fukushima
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takeshi Urade
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Shinichi So
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Toshihiko Yoshida
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Keisuke Arai
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Jun Ishida
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yoshihide Nanno
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Daisuke Tsugawa
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Hiroaki Yanagimoto
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Hirochika Toyama
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Masahiro Kido
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takumi Fukumoto
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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Chen DX, Chen SX, Hou SL, Wen GH, Yang HK, Shi DP, Lu QX, Zhai YQ, Li MY. A nomogram for prediction of ERCP success in patients with bile duct leaks: a multicenter study. Surg Endosc 2024; 38:2465-2474. [PMID: 38456946 DOI: 10.1007/s00464-024-10734-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 01/28/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Bile duct leaks (BDLs) are serious complications that occurs after hepatobiliary surgery and trauma, leading to rapid clinical deterioration. Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for BDLs, but it is not clear which patients will respond to this therapy and which patients will require additional surgical intervention. The aim of our study was to explore the predictors of successful ERCP for BDLs. METHODS A retrospective analysis was conducted using data from six centers' databases. All consecutive patients who were clinically confirmed as BDLs were included in the study. Collected data were demographics, disease severity, and ERCP procedure characteristics. Univariate and multivariate analysis were used to select independent predictive factors that affect the outcome of ERCP for BDLs, and a nomogram was established. Calibration and ROC curves were used to evaluate the models. RESULTS Four hundred and forty-eight consecutive patients were clinically confirmed as BDLs and 347 were excluded. In the 101 patients included patients, clinical success was achieved in 78 patients (77.2%). In logistic multivariable regression, two independent factors were negatively associated with the success of ERCP: SIRS (OR, 0.183; 95% CI 0.039-0.864; P = 0.032) and high-grade leak (OR 0.073; 95% CI 0.010-0.539; P = 0.010). Two independent factors were positively associated with the success of ERCP: leak-bridging drainage (OR 4.792; 95% CI 1.08-21.21; P = 0.039) and cystic duct leak (OR 6.193; 95% CI 1.03-37.17; P = 0.046). The prediction model with these four factors was evaluated using a receiver-operating characteristic (ROC) curve, which demonstrated an area under the curve of 0.9351. The calibration curve showed that the model had good predictive accuracy. CONCLUSION Leak-bridging drainage and cystic duct leak are positive predictors for the success of ERCP, while SIRS and high-grade leak are negative predictors. This prediction model with nomogram has good predictive ability and practical clinical value, and may be helpful in clinical decision-making and prognostication.
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Affiliation(s)
- De-Xin Chen
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, The First Medical Center, 28 Fuxing Road, Haidian District, Beijing, 100853, China
- Graduate School, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Sheng-Xin Chen
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, The First Medical Center, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Sen-Lin Hou
- Department of Gastroenterology and Hepatology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050035, China
| | - Gui-Hai Wen
- Department of Gastroenterology, Handan Central Hospital, Handan, 056001, China
| | - Hai-Kun Yang
- Department of Gastroenterology and Hepatology, Shanxi Provincial People's Hospital, Affiliate of Shanxi Medical University, Taiyuan, 030012, Shanxi, China
| | - Da-Peng Shi
- Department of Gastroenterology and Hepatology, First Affiliated Hospital of Army Medical University of PLA, Chongqing, 400042, China
| | - Qing-Xin Lu
- Department of Gastroenterology and Hepatology, Second Affiliated Hospital of Army Medical University of PLA, Chongqing, 400042, China
| | - Ya-Qi Zhai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, The First Medical Center, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Ming-Yang Li
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, The First Medical Center, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
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Mack CE, Klaiber U, Sauer P, Kohlhas L, Baumann L, Martin E, Mehrabi A, Buchler MW, Hackert T. Protocol of a randomised controlled phase II clinical trial investigating PREoperative endoscopic injection of BOTulinum toxin into the sphincter of Oddi to reduce bile leakage after hepatic resection: the PREBOT-II trial. BMJ Open 2023; 13:e065727. [PMID: 37730416 PMCID: PMC10514658 DOI: 10.1136/bmjopen-2022-065727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 03/18/2023] [Indexed: 09/22/2023] Open
Abstract
INTRODUCTION Bile leakage represents a major cause of morbidity following hepatic resection. Although most patients can be managed non-operatively, this complication requires diagnostics and therapeutic interventions. Preoperative endoscopic injection of botulinum toxin (BTX) into the sphincter of Oddi represents an innovative approach to prevent bile leakage. The aim of the PREBOT-II trial is to generate the first randomised controlled trial data on the safety, feasibility and efficacy of preoperative endoscopic BTX injection into the sphincter of Oddi to prevent bile leakage following hepatic resection. METHODS AND ANALYSIS The PREBOT-II trial is an investigator-initiated, exploratory, multicentre, randomised, controlled, open-label, phase II clinical trial with two parallel study groups. 70 patients scheduled for hepatic resection will be randomised to either the intervention or the control group. Patients of the intervention group will undergo preoperative endoscopic injection of BTX into the sphincter of Oddi 3-10 days before surgery, whereas in the control group only hepatic resection will be performed. The primary endpoint is the occurrence of a postoperative bile leakage within 30 days after hepatic resection according to the definition of the International Study Group of Liver Surgery. The secondary endpoints comprise further postoperative morbidity parameters such as severity of postoperative bile leakage, post-hepatectomy haemorrhage or liver failure, mortality and quality of life up to 3 months after hepatic resection. Safety and feasibility of the procedure will also be recorded. ETHICS, FUNDING AND DISSEMINATION The PREBOT-II trial has been approved by the German Federal Institute for Drugs and Medical Devices (reference number 4044932) and the Ethics Committee of Heidelberg University (reference number AFmu-558/2021). This trial is supported by the German Federal Ministry of Education and Research. The results will be presented at national and international conferences and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER DRKS00024061, EudraCT: 2020-006001-35.
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Affiliation(s)
- Claudia Eva Mack
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
- Department of General Surgery, Medical University of Vienna, Wien, Austria
| | - Peter Sauer
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Laura Kohlhas
- Institute of Medical Biometry, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Lukas Baumann
- Institute of Medical Biometry, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Eike Martin
- Patient Advocacy, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Markus W Buchler
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Hamburg, Germany
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Kouladouros K, Kähler G. [Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:469-484. [PMID: 36269350 DOI: 10.1007/s00104-022-01735-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 05/04/2023]
Abstract
Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.
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Affiliation(s)
- Konstantinos Kouladouros
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Georg Kähler
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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Wang J, Zheng Z, Wu T, Li W, Wang J, Pan Y, Peng W, Hu D, Hou J, Xu L, Zhang Y, Chen M, Zhang R, Zhou Z. Hepatic Arterial Infusion Chemotherapy as a Timing Strategy for Conversion Surgery to Treat Hepatocellular Carcinoma: A Single-Center Real-World Study. J Hepatocell Carcinoma 2022; 9:999-1010. [PMID: 36132426 PMCID: PMC9483136 DOI: 10.2147/jhc.s379326] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/09/2022] [Indexed: 01/27/2023] Open
Abstract
Objective To evaluate whether surgery-related complications are increased after hepatic arterial infusion chemotherapy (HAIC) using oxaliplatin plus fluorouracil/leucovorin for conversion compared with primary hepatocellular carcinoma (HCC) resection and the optimal timing of conversion surgery (CS). Background HAIC has been widely used for advanced HCC, especially initially unresectable HCC, to facilitate conversion to curative-intent resection in approximately 23.8% of cases. However, the optimal timing of surgery to reduce surgical complications must be clarified. Methods Data from 320 HCC patients, including 107 initially unresectable patients in the HAIC-Surgery group and 213 patients in the Surgery group, were retrospectively collected and analyzed. Survival outcomes and the incidence of surgery-related complications were compared. Results There was no significant difference in recurrence-free survival (RFS) between the HAIC-Surgery group and the Surgery group (HR: 1.140, 95% CI: 0.8027-1.618, p=0.444). The HAIC-Surgery group had a higher incidence of surgery-related complications than the Surgery group [biliary leakage (10.3% vs 4.2%, p=0.035), abdominal bleeding (10.3% vs 3.8%, p=0.020), pleural effusion (56.1% vs 23.0%, p<0.0001) and ascites effusion (17.8% vs 5.2%, p<0.0001)]. In the HAIC-Surgery group, postoperative liver function decreased and abdominal bleeding increased with more preoperative HAIC cycles (Spearman=0.229, p=0.042, Spearman=0.198, p=0.041, respectively). The pathological complete remission (pCR) rate after 3-5 HAIC cycles was significantly higher than that after 1-2 cycles (29.4% vs 13.2%, p=0.043). Conclusion The prognosis of advanced HCC after conversion surgery is comparable to that after direct surgery. Rather than increasing pCR, more HAIC cycles can exacerbate liver dysfunction and surgery-related complications.
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Affiliation(s)
- Jiongliang Wang
- Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People’s Republic of China
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, People’s Republic of China
| | - Zhikai Zheng
- Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People’s Republic of China
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, People’s Republic of China
| | - Tianqing Wu
- Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People’s Republic of China
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, People’s Republic of China
| | - Wenxuan Li
- Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People’s Republic of China
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, People’s Republic of China
| | - Juncheng Wang
- Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People’s Republic of China
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, People’s Republic of China
| | - Yangxun Pan
- Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People’s Republic of China
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, People’s Republic of China
| | - Wei Peng
- Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People’s Republic of China
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, People’s Republic of China
| | - Dandan Hu
- Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People’s Republic of China
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, People’s Republic of China
| | - Jiajie Hou
- Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People’s Republic of China
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, People’s Republic of China
| | - Li Xu
- Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People’s Republic of China
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, People’s Republic of China
| | - Yaojun Zhang
- Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People’s Republic of China
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, People’s Republic of China
| | - Minshan Chen
- Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People’s Republic of China
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, People’s Republic of China
| | - Rongxin Zhang
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, People’s Republic of China
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People’s Republic of China
| | - Zhongguo Zhou
- Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People’s Republic of China
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, People’s Republic of China
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Yoon KC, Yu YD, Kang WH, Jo HS, Kim DS. Right posterior bile duct stricture after central bisectionectomy or anterior sectionectomy. Langenbecks Arch Surg 2022; 407:2873-2880. [PMID: 35739405 DOI: 10.1007/s00423-022-02586-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 06/14/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Before performing anterior sectionectomy (AS) or central bisectionectomy (CBS), the anatomy of the right posterior bile duct (RPBD) must be cautiously assessed owing to the many variations of the RPBD and its variations could be related to bile duct injury. METHODS Clinical data of patients who underwent AS or CBS from 2009 to 2018 were reviewed. The bile duct anatomy according to Okubo's criteria and the right bile duct (RBD) length were evaluated using MRI, and we performed a risk factor analysis of the RPBD stricture (RPBDS). RESULTS A total of 68 patients were included. Type A bile ducts were the most common (n = 36, 52.9%). Five (7.2%) patients had RPBDS requiring intervention. RPBDS only occurred in patients with a type A bile duct and a type A portal vein undergoing surgery using the Glissonian sheath approach. Moreover, when the RBD length was > 12 mm, the sensitivity and specificity were 0.8 and 0.889, respectively. In multivariate analysis, RBD length of > 12 mm was significant. CONCLUSION A careful review of RPBD anatomy especially in patient with long RBD and caution when using the anterior Glissonian sheath approach might be helpful to prevent RPBDS during AS or CBS.
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Affiliation(s)
- Kyung Chul Yoon
- Division of HBP Surgery & Liver Transplantation, Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, 02841, South Korea
| | - Young-Dong Yu
- Division of HBP Surgery & Liver Transplantation, Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, 02841, South Korea
| | - Woo-Hyoung Kang
- Division of HBP Surgery & Liver Transplantation, Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, 02841, South Korea
| | - Hye-Sung Jo
- Division of HBP Surgery & Liver Transplantation, Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, 02841, South Korea
| | - Dong-Sik Kim
- Division of HBP Surgery & Liver Transplantation, Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, 02841, South Korea.
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Buechter M, Katsounas A, Saner F, Gerken G, Canbay A, Dechêne A. ERCP in critically ill patients is safe and does not increase mortality. Medicine (Baltimore) 2022; 101:e28606. [PMID: 35119004 PMCID: PMC8812702 DOI: 10.1097/md.0000000000028606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 12/14/2021] [Accepted: 12/24/2021] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for minimally-invasive treatment of biliary or pancreatic tract disease. When treating patients on intensive care units (ICU) with ERCP, interventionalists are faced with considerably higher morbidity compared to patients in ambulatory settings. However, data on complications and outcome of critical ill patients undergoing emergency ERCP are limited.A retrospective analysis of 102 patients treated on ICUs undergoing 121 ERCP procedures at the University Hospital of Essen, Germany between 2002 and 2016 was performed. Indications, interventional success, outcome including survival and procedure-related complications were analyzed. Patients' condition pre-ERCP was categorized by using the "Simplified Acute Physiology Score" (SAPS 3).66/102 patients (64.7%) were referred to ERCP from surgical ICU, 36/102 (35.3%) from nonsurgical ICU. The majority of patients were male (63.7%), the mean age was 54.1 ± 14.9 [21-88] years. Indications for ERCP were biliary complications after liver transplantation (n = 34, 33.3%), biliary leakage after hepatobiliary surgery (n = 32, 31.4%), and cholangitis/biliary sepsis (n = 36; 35.3%), respectively. 117/121 (96.7%) ERCPs were successful, 1 patient (1.0%) died during ERCP. Post-ERCP pancreatitis occurred in 11.8% of interventions. The median simplified acute physiology score 3 was 65 points, predicting a risk-adjusted estimated mortality of 48.8%, corresponding to an observed mortality of 52.2% (P = n.s.).ERCP is safe in critically ill patients on ICU, it does not increase overall mortality rate and has a relatively low rate of procedure-associated complications.
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Affiliation(s)
- Matthias Buechter
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Germany
- St. Nikolaus-Stiftshospital, Andernach, Germany
| | - Antonios Katsounas
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Germany
- Department of Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Germany
| | - Fuat Saner
- Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Germany
- Department of Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Germany
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Germany
- Department of Gastroenterology, Hepatology and Endocrinology, General Hospital Nuremberg, Germany
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10
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The Effect of Preoperative Biliary Drainage with or without Pancreatic Stenting on Complications after Pancreatoduodenectomy: A Retrospective Cohort Study. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5572395. [PMID: 33997014 PMCID: PMC8105100 DOI: 10.1155/2021/5572395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/10/2021] [Accepted: 04/16/2021] [Indexed: 12/13/2022]
Abstract
Background The necessity of preoperative biliary drainage (PBD) prior to pancreaticoduodenectomy (PD) is still controversial. However, in some settings, PBD with endoscopic retrograde cholangiopancreatography (ERCP) procedure is recommended as a preferred management. Meanwhile, pancreatic duct stenting in the drainage procedure is rarely performed for selected indications, and its associated complications after PD remain quite unknown. Methods A retrospective observational longitudinal cohort study was performed on patients who underwent PBD and PD from a prospectively maintained database at the National Cancer Center from March of 2015 to July of 2019. Patients who underwent biliary stenting alone, biliary and pancreatic stenting, were distributed into two study cohort groups, and their records were scrutinized for the incidence of postoperative complications. Results A total of 83 patients who underwent successful PD after biliary drainage were identified. 29 patients underwent nasobiliary drainage (ENBD)/plastic or metal bile duct stenting (BS) and pancreatic duct stenting (PS group), and 54 patients underwent only ENBD/BS, without pancreatic duct stenting (NPS group). No differences were found between the two groups with respect to in-hospital time, overall complication rate, respective rate of serious (grade 3 or higher) complication rate, bile anastomotic leakage, bleeding, abdominal infection, surgical wound infection, organ dysfunction, and pancreatic anastomotic leakage. Postoperative gastrointestinal dysfunction rates differed significantly, which occurred in 3 (5.56%) cases in the NPS group, compared with 6 (20.7%) cases in the PS group (P = 0.06). In the univariate and multivariate regression model analysis, pancreatic duct stenting was correlated with higher rates of gastrointestinal dysfunction [odds ratio (OR) = 4.25, P = 0.0472]. Conclusion Our data suggested that PBD and pancreatic duct stenting prior to pancreatoduodenectomy would increase the risk of postoperative delayed gastric emptying, while the overall incidence of postoperative complications and other complications, such as pancreatic leakage and bile duct leakage, showed no statistical difference.
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Citterio D, Vaiani M, Sposito C, Rossi RE, Flores M, Battiston C, Mazzaferro V. Improved management of grade B biliary leaks after complex liver resections using gadoxetic acid disodium-enhanced magnetic resonance cholangiography. Surgery 2021; 170:499-506. [PMID: 33745732 DOI: 10.1016/j.surg.2021.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Bile leaks occurring after complex liver resection and lasting >1 week (grade B) usually are managed by means of invasive cholangiography either endoscopic or percutaneous, with a substantial risk of procedure-related complications. The aim of this study was to investigate the ability of gadoxetic acid disodium-enhanced magnetic resonance cholangiography to detect postoperative biliary leaks and avoid invasive cholangiography in case of peripheral location of the fistula. METHODS Patients with grade B biliary leak after complex liver resection from January 2018 to March 2020 underwent magnetic resonance cholangiography to guide the management of the leak (study group). The primary endpoint was the ability of magnetic resonance cholangiography to reduce the need for invasive cholangiography with respect to similar posthepatectomy leaks collected in the previous 2 years and approached with upfront invasive cholangiography (controls). A series of in-hospital outcomes also were compared. RESULTS Out of 533 liver resections, 11 study patients versus 11 control patients with grade B leaks were compared. Magnetic resonance cholangiography achieved 100% accuracy in detection and location of the leak. Five out of 6 peripheral leaks healed without invasive cholangiography. Overall, 50% reduction in the use of invasive cholangiography was observed in the study versus control patients. Median healing time and hospital stay were 38 and 40 days in patients undergoing invasive cholangiography versus 10 and 11 days in patients treated conservatively (P = .007 and 0.012, respectively). Infection rate and other complications rate were 82% vs 20% (P = .01) and 35% vs 40% (P = .5), respectively. CONCLUSION Magnetic resonance cholangiography is a safe, precise, noninvasive tool to detect posthepatectomy bile leaks that can help clinicians in decision-making on conservative versus invasive treatment of fistulas.
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Affiliation(s)
- Davide Citterio
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Marta Vaiani
- Department of Radiology, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Carlo Sposito
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Roberta Elisa Rossi
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Maria Flores
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Carlo Battiston
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Vincenzo Mazzaferro
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
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12
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Smith AA, Buell JF. Authors' Reply: Bile Leak Reduction with Laparoscopic Versus Open Liver Resection: A Multi-institutional Propensity Score-Adjusted Multivariable Regression Analysis. World J Surg 2020; 44:4278. [PMID: 32901322 DOI: 10.1007/s00268-020-05778-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2020] [Indexed: 11/24/2022]
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13
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Wang J, Zhao JP, Wang JJ, Chai SS, Zhang YX, Zhang ZG, Xiang S, Chen XP, Zhang WG. The impact of bile leakage on long-term prognosis in primary liver cancers after hepatectomy: A propensity-score-matched study. Asian J Surg 2020; 43:603-612. [PMID: 31611103 DOI: 10.1016/j.asjsur.2019.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 07/16/2019] [Accepted: 08/18/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The impact of bile leakage (BL) on the long-term prognosis in patients with primary liver cancers after hepatectomy remains unclear. METHODS One thousand nine hundred and seventy-one consecutive patients with primary liver cancers who underwent curative hepatectomy were enrolled. 75 patients encountered BL, including 34 long-time BL (LTBL) and 41 short-time BL (STBL) according to 4-weeks demarcation. Variables associated with BL were identified using multiple logistic regression analysis. 75 patients without BL were enrolled into the Non-BL group using a one-to-one propensity score matched analysis before assessing the impact of BL on the long-term prognosis. The levels of interleukin-6 (IL-6) and C-reactive protein (CRP) in the serum and drain fluid were detected and compared. RESULTS The tumor size, type of liver cancer, operation time, blood loss and blood transfusion were independent risk factors for BL. The long-term survival showed no difference between the patients with and without BL (p > 0.05), while the LTBL was a significant predictor of poor long-term prognosis (p < 0.001). Compared with the patients without BL, the patients with BL had a higher level of IL-6 from postoperative day (POD) 1 to POD 60, and a higher level of CRP from POD 7 to POD 60. By POD 60, the levels of IL-6 and CRP hadn't restored to the normal level in the LTBL group. CONCLUSIONS The LTBL has a negative impact on the long-term prognosis of patients with primary liver cancers after hepatectomy, in which the inflammatory responses may play a pivotal role.
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Affiliation(s)
- Jian Wang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Department of Hepatopancreatobiliary Surgery Treatment Center, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Jian-Ping Zhao
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing-Jing Wang
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Song-Shan Chai
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu-Xin Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhan-Guo Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuai Xiang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiao-Ping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Wan-Guang Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Spetzler VN, Schepers M, Pinnschmidt HO, Fischer L, Nashan B, Li J. The incidence and severity of post-hepatectomy bile leaks is affected by surgical indications, preoperative chemotherapy, and surgical procedures. Hepatobiliary Surg Nutr 2019; 8:101-110. [PMID: 31098357 DOI: 10.21037/hbsn.2019.02.06] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Bile leaks are one of the most common complications after liver resection. The International Study Group of Liver Surgery (ISGLS) established a uniform bile leak definition including a severity grading. However, a risk factor assessment according to ISGLS grading as well as the clinical implications has not been studied sufficiently so far. Methods The incidence and grading of bile leaks according to ISGLS were prospectively documented in 501 consecutive liver resections between July 2012 and December 2016. A multivariate regression analysis was performed for risk factor assessment. Association with other surgical complications, 90-day mortality as well as length of hospital stay (LOS) was studied. Results The total rate of bile leaks in this cohort was 14.0%: 2.8% grade A, 8.0% grade B, and 3.2% grade C bile leaks were observed. Preoperative chemotherapy or biliary intervention, diagnosis of hilar cholangiocarcinoma, colorectal metastasis, central minor liver resection, major hepatectomy, extended hepatectomy or two-stage hepatectomy, were some of the risk factors leading to bile leaks. The multivariate regression analysis revealed that preoperative chemotherapy, major hepatectomy and biliodigestive reconstruction remained significant independent risk factors for bile leaks. Grade C bile leaks were associated not only with surgical site infection, but also with an increased 90-day mortality and prolonged LOS. Conclusions The preoperative treatment as well as the surgical procedure had significant influence on the incidence and the severity of bile leaks. Grade C bile leaks were clinically most relevant, and led to significant increased LOS, rate of infection, and mortality.
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Affiliation(s)
- Vinzent N Spetzler
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlene Schepers
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans O Pinnschmidt
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lutz Fischer
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Björn Nashan
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jun Li
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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