1
|
Yanagisawa Y, Al-Nae’eb Y, Chrysostomou P, Gercek Y. Delayed Extrahepatic Biliary Leak: A Rare Presentation 9 Years Post-Laparoscopic Cholecystectomy. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e941230. [PMID: 37971966 PMCID: PMC10660308 DOI: 10.12659/ajcr.941230] [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: 05/25/2023] [Revised: 10/13/2023] [Accepted: 09/19/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Biliary leaks are an important cause of the acute abdomen condition, carrying significant levels of morbidity and mortality. They are most commonly the result of acute iatrogenic or blunt trauma, with an identifiable cause. In comparison, spontaneous and delayed biliary leaks are rare phenomena occurring in the absence of recent surgery, endoscopic intervention, or trauma. Here we report the case of a 77-year-old woman presenting with acute abdominal pain, distension, and rigors caused by an extrahepatic biliary leakage 9 years after laparoscopic cholecystectomy. CASE REPORT Laparoscopic hepatobiliary intervention, rather than open surgery, is associated with increased risk of biliary tree injury, including biliary leaks, which typically arise in the immediate postoperative period. This report concerns a 77-year-old woman presenting with acute abdominal pain, distension, and rigors due to extrahepatic biliary leakage 9 years following elective laparoscopic cholecystectomy for cholelithiasis. Computed tomography (CT) showed large-volume abdominopelvic ascites with no obvious source. Intra-abdominal exploration revealed a large biloma with 2 lacerations in the gallbladder fossa. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) found only a vague leak in the extrahepatic biliary tree, with no focal defect or retained biliary calculi. Intra-abdominal drainage and common bile duct (CBD) stenting were performed. Repeat ERCP undertaken 3 months later, however, identified a calculus within the CBD. CONCLUSIONS The patient's rare presentation of biliary leakage 9 years after cholecystectomy raises the question of whether the condition was delayed or spontaneous in nature. The biliary calculus identified 3 months following the leakage raises the possibility of retained biliary calculi.
Collapse
Affiliation(s)
- Yuuki Yanagisawa
- Department of Internal Medicine, Bedfordshire Hospitals NHS Trusts, Bedford Hospital, Bedford, UK
| | - Yasseen Al-Nae’eb
- Department of Gastroenterology and Hepatology, Bedfordshire Hospitals NHS Trusts, Bedford Hospital, Bedford, UK
| | - Paris Chrysostomou
- Department of Cardiology, Bedfordshire Hospitals NHS Trusts, Bedford Hospital, Bedford, UK
| | - Yuksel Gercek
- Department of General Surgery, Bedfordshire Hospitals NHS Trusts, Bedford Hospital, Bedford, UK
| |
Collapse
|
2
|
Bickel A, Lagrissi R, Jerushalmi J, Sbeit W, Weiss M, Shiller M, Ganam S, Kakiashvili E. The Role of Hepatobiliary Scintigraphy as the Initial Investigative Modality for Significant Bile Leak following Laparoscopic Cholecystectomy. Dig Surg 2023; 40:178-186. [PMID: 37748452 DOI: 10.1159/000533794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/23/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION Currently, the rate of bile duct injury and leak following laparoscopic cholecystectomy (LC) is still higher than for open surgery. Diverse investigative algorithms were suggested for bile leak, shifting from hepatobiliary scintigraphy (HBS) toward invasive and more sophisticated means. We aimed to analyze the use of biliary scan as the initial modality to investigate significant bile leak in the drain following LC, attempting to avoid potential unnecessary invasive means when the scan demonstrate fair passage of nuclear substance to the intestine, without leak. METHODS We have conducted a prospective non-randomized study, mandating hepatobiliary scintigraphy first, for asymptomatic patients harboring drain in the gallbladder fossa, leaking more than 50 mL/day following LC. Analysis was done based on medical data from the surgical, gastroenterology, and the nuclear medicine departments. RESULTS Among 3,124 patients undergoing LC, significant bile leak in the drain was seen in 67 subjects, of whom we started with HBS in 50 patients, presenting our study group. In 27 of whom, biliary scan was the only investigative modality, showing fair passage of the nuclear isotope to the duodenum and absence of leak in the majority. The leak stopped spontaneously within a mean of 3.6 days, and convalescence as well as outpatient clinic follow-up was uneventful. In 23 patients, biliary scan that was interpreted as abnormal was followed by endoscopic retrograde cholangio-pancreatography (ERCP). However, ERCP did not demonstrate any bile leak in 13 subjects. In 17 patients, ERCP was used initially, without biliary scan, suggesting the possibility of avoiding invasive modalities in 7 patients. CONCLUSIONS Based on a negative predictive value of 91%, we suggest that in cases of asymptomatic significant bile leak through a drain following LC, a normal HBS as the initial modality can safely decrease the rate of using invasive modalities.
Collapse
Affiliation(s)
- Amitai Bickel
- Departments of Surgery A, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
| | - Ron Lagrissi
- Departments of Surgery A, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
| | - Jacqueline Jerushalmi
- Nuclear Medicine Institute, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
| | - Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
| | - Michael Weiss
- Departments of Surgery A, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
| | - Moshe Shiller
- Department of Gastroenterology, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
| | - Samer Ganam
- Departments of Surgery A, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
| | - Eli Kakiashvili
- Departments of Surgery A, Galilee Medical Center, The Azrieli Faculty of Medicine, Bar-Ilan University, Nahariya, Israel
| |
Collapse
|
3
|
Tomihara H, Tomimaru Y, Hashimoto K, Fukuchi N, Yokoyama S, Mori T, Tanemura M, Sakai K, Takeda Y, Tsujie M, Yamada T, Miyamoto A, Hashimoto Y, Hatano H, Shimizu J, Sugimoto K, Kashiwazaki M, Matsumoto K, Kobayashi S, Doki Y, Eguchi H. Preoperative risk score to predict subtotal cholecystectomy after gallbladder drainage for acute cholecystitis: Secondary analysis of data from a multi-institutional retrospective study (CSGO-HBP-017B). Asian J Endosc Surg 2022; 15:555-562. [PMID: 35302288 DOI: 10.1111/ases.13051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/14/2022] [Accepted: 02/19/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Subtotal cholecystectomy (STC) has become recognized as a "bailout procedure" to prevent bile duct injury in patients undergoing laparoscopic cholecystectomy (LC). Predictors of conversion to STC have not been identified because LC difficulty varies based on pericholecystic inflammation. We analyzed data from patients enrolled in a previously performed multi-institutional retrospective study of the optimal timing of LC after gallbladder drainage for acute cholecystitis (AC). These patients presumably had a considerable degree of pericholecystic inflammation. METHODS In total, 347 patients who underwent LC after gallbladder drainage for AC were analyzed to examine preoperative and perioperative factors predicting conversion to STC. RESULTS Three hundred patients underwent total cholecystectomy (TC) and 47 underwent conversion to STC. Eastern Cooperative Oncology Group Performance Status (ECOG PS) (P < .01), severity of cholecystitis (P = .04), previous history of treatment for common bile duct stones (CBDS) (P < .01), and surgeon experience (P = .03) were significantly associated with conversion to STC. Logistic regression analyses showed that ECOG PS (odds ratio 0.2; P < .0001) and previous history of treatment for CBDS (odds ratio 0.37; P = .0073) were independent predictors of conversion to STC. Our predictive risk score using these two variables suggested that a score ≥2 could discriminate between TC and STC (P < .0001). CONCLUSION Poor ECOG PS and previous history of treatment for CBDS were significantly associated with conversion to STC after gallbladder drainage for AC.
Collapse
Affiliation(s)
- Hideo Tomihara
- Department of Surgery, Faculty of Medicine, Nara Hospital, Kindai University, Ikoma, Japan.,Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan
| | - Yoshito Tomimaru
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Kazuhiko Hashimoto
- Department of Surgery, Faculty of Medicine, Nara Hospital, Kindai University, Ikoma, Japan.,Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan
| | - Nariaki Fukuchi
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Suita Municipal Hospital, Suita, Japan
| | - Shigekazu Yokoyama
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya, Japan
| | - Takuji Mori
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Tane General Hospital, Osaka, Japan
| | - Masahiro Tanemura
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Osaka Police Hospital, Osaka, Japan.,Department of Surgery, Rinku General Medical Center, Osaka, Japan
| | - Kenji Sakai
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Japan Community Health Care Organization, Osaka Hospital, Osaka, Japan
| | - Yutaka Takeda
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Kansai Rosai Hospital, Amagasaki, Japan
| | - Masanori Tsujie
- Department of Surgery, Faculty of Medicine, Nara Hospital, Kindai University, Ikoma, Japan.,Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Osaka Rosai Hospital, Sakai, Japan
| | - Terumasa Yamada
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
| | - Atsushi Miyamoto
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan.,Department of Surgery, Sakai City Medical Center, Sakai, Japan
| | - Yasuji Hashimoto
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Yao Municipal Hospital, Yao, Japan
| | - Hisanori Hatano
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Osaka Police Hospital, Osaka, Japan.,Department of Surgery, Ashiya Municipal Hospital, Ashiya, Japan
| | - Junzo Shimizu
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan.,Department of Surgery, Osaka Rosai Hospital, Sakai, Japan
| | - Keishi Sugimoto
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Minoh City Hospital, Minoh, Japan.,Department of Surgery, Kawanishi City Hospital, Kawanishi, Japan
| | - Masaki Kashiwazaki
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Osaka General Medical Center, Osaka, Japan.,Department of Surgery, Otemae Hospital, Osaka, Japan
| | - Kenichi Matsumoto
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Shogo Kobayashi
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Yuichiro Doki
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hidetoshi Eguchi
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| |
Collapse
|
4
|
Sharma A, Ruch B, Alwatari Y, Lele S, Bouhaidar D. Delayed, recurrent bile leak from isolated right posterior sectoral duct injury after laparoscopic cholecystectomy: An unusual presentation. Clin Case Rep 2022; 10:e6032. [PMID: 35865786 PMCID: PMC9291261 DOI: 10.1002/ccr3.6032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/07/2022] [Accepted: 06/11/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Amit Sharma
- Hume‐Lee Transplant Center Virginia Commonwealth University Richmond Virginia USA
| | - Brianna Ruch
- Hume‐Lee Transplant Center Virginia Commonwealth University Richmond Virginia USA
| | - Yahya Alwatari
- Hume‐Lee Transplant Center Virginia Commonwealth University Richmond Virginia USA
| | - Sonia Lele
- Hume‐Lee Transplant Center Virginia Commonwealth University Richmond Virginia USA
| | - Doumit S. Bouhaidar
- Division of Gastroenterology Virginia Commonwealth University Richmond Virginia USA
| |
Collapse
|
5
|
Madhusudhan KS, Jineesh V, Keshava SN. Indian College of Radiology and Imaging Evidence-Based Guidelines for Percutaneous Image-Guided Biliary Procedures. Indian J Radiol Imaging 2021; 31:421-440. [PMID: 34556927 PMCID: PMC8448229 DOI: 10.1055/s-0041-1734222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Percutaneous biliary interventions are among the commonly performed nonvascular radiological interventions. Most common of these interventions is the percutaneous transhepatic biliary drainage for malignant biliary obstruction. Other biliary procedures performed include percutaneous cholecystostomy, biliary stenting, drainage for bile leaks, and various procedures like balloon dilatation, stenting, and large-bore catheter drainage for bilioenteric or post-transplant anastomotic strictures. Although these procedures are being performed for ages, no standard guidelines have been formulated. This article attempts at preparing guidelines for performing various percutaneous image-guided biliary procedures along with discussion on the published evidence in this field.
Collapse
Affiliation(s)
| | - Valakkada Jineesh
- Department of Radiology, Sree Chitra Tirunal Institute of Medical Sciences and Technology (Thiruvananthapuram), Kerala, India
| | | |
Collapse
|
6
|
Micheli D, Patel KR, Li T, Kassir M, Eichorn W. Spontaneous Bile Leak in a Patient Without Recent Abdominal Surgery or Trauma. Cureus 2021; 13:e16702. [PMID: 34466328 PMCID: PMC8397512 DOI: 10.7759/cureus.16702] [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] [Accepted: 07/28/2021] [Indexed: 11/05/2022] Open
Abstract
Bile leaks are a rare occurrence most often seen as a complication of cholecystectomy. Other less common etiologies include endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), liver surgery, percutaneous drainage of liver abscesses, living donor hepatectomy, and non-iatrogenic abdominal trauma. In this case study, we present a 67-year-old female with morbid obesity who presented with abdominal pain and was diagnosed with a spontaneous bile leak. She had no history of recent surgery or abdominal trauma. CT revealed that the patient's gallbladder was located in the right lower quadrant, most likely due to mass effect from a large ventral hernia, and possible fluid collection extending from the gallbladder along the surface of the anterior inferior right hepatic lobe. Hepatobiliary iminodiacetic acid (HIDA) was performed due to a concern for cholecystitis. HIDA demonstrated a bile leak in the right upper abdomen of unknown etiology. Initially, there was a concern for gallbladder obstruction. Gastroenterology recommended magnetic resonance cholangiopancreatography (MRCP), however, MRCP was not possible due to the patient's body habitus. The patient had normal liver function tests, was tolerating oral intake, and her abdominal pain resolved, therefore, we became less suspicious of gallbladder obstruction. This case suggests that bile leak should be included in the differential diagnosis for abdominal pain even in patients who have not had recent abdominal surgery or procedures. This case also highlights the unique anatomical finding of a right lower quadrant gallbladder secondary to mass effect from a large ventral hernia.
Collapse
Affiliation(s)
- Daniel Micheli
- Family and Community Medicine, Western Michigan University Homer Stryker School of Medicine, Kalamazoo, USA
| | - Keshav R Patel
- Internal Medicine, Western Michigan University Homer Stryker School of Medicine, Kalamazoo, USA
| | - Tong Li
- Family and Community Medicine, Western Michigan University Homer Stryker School of Medicine, Kalamazoo, USA
| | - Mahmoud Kassir
- Family and Community Medicine, Western Michigan University Homer Stryker School of Medicine, Kalamazoo, USA
| | - Wesley Eichorn
- Family and Community Medicine, Western Michigan University Homer Stryker School of Medicine, Kalamazoo, USA
| |
Collapse
|
7
|
Nassar AHM, Ng HJ. Risk identification and technical modifications reduce the incidence of post-cholecystectomy bile leakage: analysis of 5675 laparoscopic cholecystectomies. Langenbecks Arch Surg 2021; 407:213-223. [PMID: 34436660 PMCID: PMC8847250 DOI: 10.1007/s00423-021-02264-z] [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: 01/22/2021] [Accepted: 07/01/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE The main sources of post-cholecystectomy bile leakage (PCBL) not involving major duct injuries are the cystic duct and subvesical/hepatocystic ducts. Of the many studies on the diagnosis and management of PCBL, few addressed measures to avoid this serious complication. The aim of this study was to examine the causes and mechanisms leading to PCBL and to evaluate the effects of specific preventative strategies. METHODS A prospectively maintained database of 5675 consecutive laparoscopic cholecystectomies was analysed. Risk factors for post-cholecystectomy bile leakage were identified and documented and technical modifications and strategies were adopted to prevent this complication. The incidence, causes and management of patients who suffered bile leaks were studied and their preoperative characteristics, operative data and postoperative outcomes were compared with patients where potential risks were identified and PCBL avoided and with the rest of the series. RESULTS Twenty-five patients (0.4%) had PCBL (7 expected and less than half requiring reintervention): 11 from cystic ducts (0.2%), 3 from subvesical ducts (0.05%) and 11 from unconfirmed sources (0.2%). The incidence of cystic duct leakage was significantly lower with ties (0.15%) than with clips (0.7%). Fifty-two percent had difficulty grades IV or V, 36% had empyema or acute cholecystitis and 16% had contracted gallbladders. Twelve patients required 17 reinterventions before PCBL resolved; 7 percutaneous drainage, 6 ERCP and 4 relaparoscopy. The median hospital stay was 17 days with no mortality. Hepatocystic ducts were encountered in 72 patients (1.3%) and were secured with loops (54.2%), ties (25%) or sutures (20.8%) with no PCBL. Eighteen sectoral ducts were identified and secured. CONCLUSION Ligation of the cystic duct reduces the incidence of PCBL resulting from dislodged endoclips. Careful blunt dissection in the proper anatomical planes avoiding direct or thermal injury to subvesical and sectoral ducts and a policy of actively searching for hepatocystic ducts during gallbladder separation to identify and secure them can reduce bile leakage from such ducts.
Collapse
Affiliation(s)
- Ahmad H M Nassar
- Laparoscopic Biliary Surgery Service, University Hospital Monklands, Lanarkshire, Airdrie, Scotland, ML6 0JS, UK.
| | | |
Collapse
|
8
|
Benign Bile Duct Strictures. Indian J Surg 2021. [DOI: 10.1007/s12262-019-02060-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
|
9
|
Endoscopic Ultrasound-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography for Removal of Cystic Duct Coils: A Novel Application of an Emerging Technique. ACG Case Rep J 2021; 8:e00576. [PMID: 34007855 PMCID: PMC8126554 DOI: 10.14309/crj.0000000000000576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 12/02/2020] [Indexed: 11/17/2022] Open
Abstract
The altered anatomy of patients after Roux-en-Y gastric bypass (RYGB) surgery creates technical challenges for endoscopic and surgical treatment of gallstones. We present a unique case of a post-RYGB patient with complicated gallbladder surgery requiring coiling and embolization of the cystic duct for bile leak. The cystic duct coils migrated out into the bile duct forming a nidus for infection and biliary obstruction, which was resolved using the novel endoscopic ultrasound–directed transgastric routine endoscopic retrograde cholangiopancreatography technique, with successful transpapillary removal of cystic duct coils in RYGB anatomy.
Collapse
|
10
|
Sharma C, Singh H, Orihuela-Espina F, Darzi A, Sodergren MH. Visual gaze patterns reveal surgeons' ability to identify risk of bile duct injury during laparoscopic cholecystectomy. HPB (Oxford) 2021; 23:715-722. [PMID: 32988756 DOI: 10.1016/j.hpb.2020.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/07/2020] [Accepted: 09/09/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bile duct injury is a serious surgical complication of laparoscopic cholecystectomy. The aim of this study was to identify distinct visual gaze patterns associated with the prompt detection of bile duct injury risk during laparoscopic cholecystectomy. METHODS Twenty-nine participants viewed a laparoscopic cholecystectomy that led to a serious bile duct injury ('BDI video') and an uneventful procedure ('control video') and reported when an error was perceived that could result in bile duct injury. Outcome parameters include fixation sequences on anatomical structures and eye tracking metrics. Surgeons were stratified into two groups based on performance and compared. RESULTS The 'early detector' group displayed reduced common bile duct dwell time in the first half of the BDI video, as well as increased cystic duct dwell time and Calot's triangle glances count during Calot's triangle dissection in the control video. Machine learning based classification of fixation sequences demonstrated clear separability between early and late detector groups. CONCLUSION There are discernible differences in gaze patterns associated with early recognition of impending bile duct injury. The results could be transitioned into real time and used as an intraoperative early warning system and in an educational setting to improve surgical safety and performance.
Collapse
Affiliation(s)
- Chetanya Sharma
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, United Kingdom
| | - Harsmirat Singh
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, United Kingdom
| | | | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, United Kingdom
| | - Mikael H Sodergren
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, United Kingdom.
| |
Collapse
|
11
|
Nzenwa IC, Mesri M, Lunevicius R. Risks associated with subtotal cholecystectomy and the factors influencing them: A systematic review and meta-analysis of 85 studies published between 1985 and 2020. Surgery 2021; 170:1014-1023. [PMID: 33926707 DOI: 10.1016/j.surg.2021.03.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/05/2021] [Accepted: 03/12/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Subtotal cholecystectomy is recognized as a rescue procedure performed in grossly suboptimal circumstances that would deem a total cholecystectomy too risky to execute. An earlier systematic review based on 30 studies published between 1985 and 2013 concluded that subtotal cholecystectomy had a morbidity rate comparable to that of total cholecystectomy. This systematic review appraises 17 clinical outcomes in patients undergoing subtotal cholecystectomy. METHODS The study protocol was registered with the International Prospective Register for Systematic Reviews (CRD42020172808). MEDLINE, Embase, Cochrane bibliographic databases, and Google Scholar were used to identify papers published between 1985 and June 2020. Data related to the surgical setting, approach, intervention on the hepatic wall of the gallbladder, type of completion of subtotal cholecystectomy, year of study, and study design were collected. Seventeen clinical outcomes were considered. Meta-analyses were performed using a random-effects model, and the effect size was presented as risk ratios with 95% confidence intervals. RESULTS From 1,017 records, 85 eligible studies were identified and included. These included 3,645 patients who underwent subtotal cholecystectomy. Laparoscopic (80.1%, n = 2,918) and reconstituting (74.6%, n = 2,719) approaches represented the majority of all subtotal cholecystectomy cases. Seven (0.2%) cases of injury to the bile duct were reported. Bile leak was reported in 506 (13.9%) patients. Reconstituting subtotal cholecystectomy was associated with a lower risk for 11 clinical outcomes. Open subtotal cholecystectomy was associated with an increased rate of 30-day mortality and wound infections. CONCLUSION Subtotal cholecystectomy is associated with significant morbidity. Laparoscopic and reconstituting surgery may reduce the risks of some perioperative complications and long-term sequelae after subtotal cholecystectomy.
Collapse
Affiliation(s)
| | - Mina Mesri
- North West Schools of Surgery, Health Education England, Liverpool, United Kingdom
| | - Raimundas Lunevicius
- Department of General Surgery, Liverpool University Hospitals NHS Foundation Trust, United Kingdom.
| |
Collapse
|
12
|
Spence C, Ahmad F, Bolton L, Parekh A. Unusual cause of gas complicating a biloma, postcholecystectomy. BMJ Case Rep 2021; 14:14/4/e240437. [PMID: 33858887 PMCID: PMC8055146 DOI: 10.1136/bcr-2020-240437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 50-year-old man presented to the emergency department with abdominal pain, vomiting and fever. He had been admitted 6 months ago with acute cholecystitis when he underwent endoscopic retrograde cholangiopancreatography (ERCP) to remove ductal gallstones. Elective cholecystectomy was performed 3 days prior to the current admission. CT demonstrated a fluid and gas containing collection in the gallbladder fossa, biliary gas and free intra-abdominal gas. ERCP revealed a retained common bile duct gallstone and leakage from the cystic duct remnant. We postulate that the gas within the collection originated from intrahepatic gas post-ERCP or from a gas forming organism. The free intra-abdominal gas originated from the collection rather than an intraoperative bowel injury. This complicated case highlights an unusual appearance of a common complication. It demonstrates the importance of discussion with the clinical team to ensure that an accurate diagnosis is made and the correct treatment is provided.
Collapse
Affiliation(s)
- Cameron Spence
- Radiology Department, University Hospitals Dorset NHS Foundation Trust, Poole, UK .,Radiology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Fatima Ahmad
- Radiology Department, University Hospitals Dorset NHS Foundation Trust, Poole, UK.,Radiology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Louisa Bolton
- Emergency Medicine, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
| | - Amit Parekh
- Radiology Department, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| |
Collapse
|
13
|
Lin YH, Lin CW, Yin WY. Subvesical Duct Detected by Magnetic Resonance Cholangiopancreatography (MRCP) in a Patient with Bile Leak after Laparoscopic Cholecystectomy. CRSLS : MIS CASE REPORTS FROM SLS 2021; 8:CRSLS.2020.00074. [PMID: 36017472 PMCID: PMC9387397 DOI: 10.4293/crsls.2020.00074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Yi-Hsuan Lin
- Department of Clinical Education, Taipei Tzu Chi Hospital, Buddhist Tzu, Chi Medical Foundation, New Taipei, Taiwan
| | - Chih-Wen Lin
- Department of Radiology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi, Medical Foundation, Chiayi, Taiwan
| | - Wen-Yao Yin
- Department of Surgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| |
Collapse
|
14
|
Current Scenario of Postcholecystectomy Bile Leak and Bile Duct Injury at a Tertiary Care Referral Centre of Nepal. Minim Invasive Surg 2020; 2020:4382307. [PMID: 32373362 PMCID: PMC7191355 DOI: 10.1155/2020/4382307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 03/17/2020] [Accepted: 04/04/2020] [Indexed: 11/29/2022] Open
Abstract
Objective With the adoption of safe cholecystectomy principles at an academic institute, the risk of major bile duct injury has decreased. This study aims at evaluating the present status of bile duct injury, compared to the study published in 2013 by index centre. Methods This is a retrospective review of a prospectively maintained database of bile leak and bile duct injury from 2014 to 2019. Patients who completed postcholecystectomy bile leak or bile duct injury treatment and were on regular follow-up were included. Results Eighteen patients (0.78%) among 2,300 consecutive cholecystectomies presented with bile duct injury, including 8 (0.35%) major bile duct injuries and 10 (0.43%) bile leaks compared to major bile duct injury rate of 0.68% (92/11,345 cholecystectomies) between 2001 and 2010. Injuries were classified as Strasberg's type A (52.9%), type D (5.9%), and type E (41.1%). Eight patients (47%) of bile leak were managed conservatively with drains, while two required laparotomy and lavage. The mean time for spontaneous closure of bile leak was 11 days. Intraoperative repair was done in three cases: Roux en Y hepaticojejunostomy in 2 and end-to-end repair over T-tube in 1 for sharp transection of the duct. Delayed repair (Roux-en-Y hepaticojejunostomy) was done in five patients. The median postcholecystectomy hospital stay was 8 days, with no mortality. There was no restricture at a median follow-up of 13 months. Conclusion With the adoption of a safe culture of cholecystectomy, the major bile duct injury rate has decreased currently. Repair of bile duct injury by experienced hepatobiliary surgeon results in excellent outcome.
Collapse
|
15
|
Guerra F, Coletta D, Gavioli M, Coco D, Patriti A. Minimally invasive surgery for the management of major bile duct injury due to cholecystectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:157-163. [PMID: 31945263 DOI: 10.1002/jhbp.710] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/14/2019] [Accepted: 12/19/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Francesco Guerra
- Division of General Surgery Ospedali Riuniti Marche Nord Pesaro Italy
| | - Diego Coletta
- Division of General Surgery Ospedali Riuniti Marche Nord Pesaro Italy
| | - Manuel Gavioli
- Division of General Surgery Ospedali Riuniti Marche Nord Pesaro Italy
| | - Danilo Coco
- Division of General Surgery Ospedali Riuniti Marche Nord Pesaro Italy
| | - Alberto Patriti
- Division of General Surgery Ospedali Riuniti Marche Nord Pesaro Italy
| |
Collapse
|
16
|
Management of a Persistent Cystic Duct Stump Leak Following Cholecystectomy With Percutaneous Transabdominal Cystic Duct Stump Embolization. ACG Case Rep J 2019; 6:e00162. [PMID: 31737701 PMCID: PMC6791622 DOI: 10.14309/crj.0000000000000162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 05/31/2019] [Indexed: 11/19/2022] Open
Abstract
Cystic duct stump leak remains a difficult clinical problem despite advancements in endoscopic techniques. When these minimally invasive strategies fail, patients are often subject to high morbidity and mortality associated with open surgical exploration. We report the successful treatment of persistent biliary leak from the cystic duct stump following cholecystectomy using percutaneous transabdominal access of the cystic duct and coil embolization.
Collapse
|
17
|
Gupta R, Andley M, Pusuluri R, Kumar A. Late Presentation of Chronic-Organised Biloma Masquerading as Gallbladder Fossa Mass Years After Cholecystectomy: a Diagnostic Enigma. Indian J Surg Oncol 2019; 10:318-320. [PMID: 31168255 DOI: 10.1007/s13193-018-0854-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 12/04/2018] [Indexed: 11/25/2022] Open
Affiliation(s)
- Rigved Gupta
- Department of Surgery, Lady Hardinge Medical College & Smt. Sucheta Kriplani Hospital, New Delhi, 110001 India
| | - Manoj Andley
- Department of Surgery, Lady Hardinge Medical College & Smt. Sucheta Kriplani Hospital, New Delhi, 110001 India
| | - Rahul Pusuluri
- Department of Surgery, Lady Hardinge Medical College & Smt. Sucheta Kriplani Hospital, New Delhi, 110001 India
| | - Ajay Kumar
- Department of Surgery, Lady Hardinge Medical College & Smt. Sucheta Kriplani Hospital, New Delhi, 110001 India
| |
Collapse
|
18
|
Kumar S, Chandra A. Management of bile leak from subvesical duct (duct of Luschka) during laparoscopic cholecystectomy. Turk J Surg 2018; 37:1-2. [PMID: 30269752 PMCID: PMC8448569 DOI: 10.5152/turkjsurg.2018.4016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/05/2018] [Indexed: 11/22/2022]
Affiliation(s)
- Saket Kumar
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, India
| | - Abhijit Chandra
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, India
| |
Collapse
|
19
|
Percutaneous embolization of cystic duct stump leak following failed endoscopic management. Radiol Case Rep 2018; 12:786-789. [PMID: 29484071 PMCID: PMC5823386 DOI: 10.1016/j.radcr.2017.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 06/26/2017] [Indexed: 11/21/2022] Open
Abstract
A case of a 79-year-old man, status post laparoscopic cholecystectomy with a drainage catheter placed at the gallbladder fossa is presented. The case was complicated postoperatively by abdominal pain and bilious discharge from the drainage catheter. Endoscopic retrograde cholangio-pancreatography demonstrated leakage through the cystic duct stump into the gallbladder fossa. Placement of a covered metal stent endoscopically failed to seal the leak. We performed percutaneous embolization of the cystic duct stump using a combination of coils and gelatin sponge through the drainage catheter in the gallbladder fossa. To our knowledge, this technique has not been previously described in the literature.
Collapse
|
20
|
Abstract
Postoperative peritonitis is still a life-threatening complication after abdominal surgery and approximately 10,000 patients annually develop postoperative peritonitis in Germany. Early recognition and diagnosis before the onset of sepsis has remained a clinical challenge as no single specific screening test is available. The aim of therapy is a rapid and effective control of the source of infection and antimicrobial therapy. After diagnosis of diffuse postoperative peritonitis surgical revision is usually inevitable after intestinal interventions. Peritonitis after liver, biliary or pancreatic surgery is managed as a rule by means of differentiated therapy approaches depending on the severity.
Collapse
Affiliation(s)
- J F Lock
- Klinik & Poliklinik für Allgemein- und Viszeralchirurgie, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - C Eckmann
- Klinik für Allgemein-, Viszeral-,Thorax- und Minimal-Invasive Chirurgie, Klinikum Peine, Peine, Deutschland
| | - C-T Germer
- Klinik & Poliklinik für Allgemein- und Viszeralchirurgie, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| |
Collapse
|
21
|
Aytaç HÖ, Çalışkan K. A Rare Cause of Acute Pancreatitis: Unexpected Travel of the Biliary Catheter. Balkan Med J 2016; 33:117-8. [PMID: 26966629 DOI: 10.5152/balkanmedj.2015.15300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 08/23/2015] [Indexed: 11/22/2022] Open
Affiliation(s)
- Hüseyin Özgür Aytaç
- Department of General Surgery, Başkent University Faculty of Medicine, Adana, Turkey
| | - Kenan Çalışkan
- Department of General Surgery, Başkent University Faculty of Medicine, Adana, Turkey
| |
Collapse
|
22
|
Canena J, Horta D, Coimbra J, Meireles L, Russo P, Marques I, Ricardo L, Rodrigues C, Capela T, Carvalho D, Loureiro R, Dias AM, Ramos G, Coutinho AP, Romão C, Veiga PM. Outcomes of endoscopic management of primary and refractory postcholecystectomy biliary leaks in a multicentre review of 178 patients. BMC Gastroenterol 2015; 15:105. [PMID: 26285593 PMCID: PMC4545536 DOI: 10.1186/s12876-015-0334-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 08/10/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Biliary leaks have been treated with endoscopic management using different techniques with conflicting results. Furthermore the appropriate rescue therapy for refractory leaks has not been established. We evaluated the clinical effectiveness of initial endotherapy for postcholecystectomy biliary leaks using an homogenous approach (sphincterotomy + placement of a 10-French plastic stent) in a large series of patients as well as the optimal and efficacy of rescue endotherapy for refractory biliary leaks. METHODS This was a multicenter, retrospective study of 178 patients who underwent endoscopic management of postcholecystectomy biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore (10-French) plastic stent. Data were collected to analyze the clinical outcomes and technical success, efficacy of the rescue endotherapy and the need for surgery, adverse events and prognostic factors for clinical success of endotherapy. RESULTS Following endotherapy, closure of the leak was accomplished in 162/178 patients (91.0%). The multivariate logistic model showed that the type of leak, namely a high-grade biliary leak, was the only independent prognostic factor associated with treatment failure (OR = 26.78; 95% CI = 6.59-108.83; P < 0.01). The remaining 16 patients were treated with multiple plastic stents (MPSs) with a success rate of 62.5% (10 patients). The use of fewer than 3 plastic stents (P = 0.023) and a high-grade biliary leak (P = 0.034) were shown to be significant predictors of treatment failure with MPSs in refractory bile leaks. The 6 patients in whom the placement of MPSs failed were retreated with a fully cover self-expandable metallic stent (FCSEMS), resulting in closure of the leak in all cases. CONCLUSIONS Endotherapy of biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore plastic stent is associated with a high rate of success (90%). However in our series there were several failures using MPSs as a strategy for rescue endotherapy suggesting that refractory biliary leaks should be treated with FCSEMS especially in patients with high-grade leaks.
Collapse
Affiliation(s)
- Jorge Canena
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
- Department of Endoscopy, José Joaquim Fernandes Hospital at Unidade Local de Saúde do Baixo Alentejo, Rua Doutor António Fernandes Covas Lima, 7800-309, Beja, Portugal.
| | - David Horta
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
| | - João Coimbra
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Liliane Meireles
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Pedro Russo
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Inês Marques
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Leonel Ricardo
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
| | - Catarina Rodrigues
- Department of Gastroenterology, Doutor Fernando Fonseca Hospital, IC 19, 2720-276, Amadora, Portugal.
| | - Tiago Capela
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Diana Carvalho
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Rafaela Loureiro
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - António Mateus Dias
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - Gonçalo Ramos
- Department of Gastroenterology, Santo António dos Capuchos Hospital at Centro Hospitalar Lisboa Central, Nova Medical School-Faculty of Medical Sciences, Alameda Santo António dos Capuchos, 1169-050, Lisbon, Portugal.
| | - António Pereira Coutinho
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Carlos Romão
- Department of Gastroenterology, Pulido Valente Hospital at Centro Hospitalar Lisboa Norte, Alameda das Linhas de Torres n° 117, 1769-001, Lisbon, Portugal.
| | - Pedro Mota Veiga
- Curva de Gauss - Research, Training and Consulting, Rua Doutor Eduardo Maria dos Santos, Lote 1, Loja 3, 3525-000, Canas de Senhorim, Portugal.
| |
Collapse
|
23
|
Canena J, Liberato M, Meireles L, Marques I, Romão C, Coutinho AP, Neves BC, Veiga PM. A non-randomized study in consecutive patients with postcholecystectomy refractory biliary leaks who were managed endoscopically with the use of multiple plastic stents or fully covered self-expandable metal stents (with videos). Gastrointest Endosc 2015; 82:70-8. [PMID: 25771064 DOI: 10.1016/j.gie.2014.11.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 11/21/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic management of postcholecystectomy biliary leaks is widely accepted as the treatment of choice. However, refractory biliary leaks after a combination of biliary sphincterotomy and the placement of a large-bore (10F) plastic stent can occur, and the optimal rescue endotherapy for this situation is unclear. OBJECTIVE To compare the clinical effectiveness of the use of a fully covered self-expandable metal stent (FCSEMS) with the placement of multiple plastic stents (MPS) for the treatment of postcholecystectomy refractory biliary leaks. DESIGN Prospective study. SETTING Two tertiary-care referral academic centers and one general district hospital. PATIENTS Forty consecutive patients with refractory biliary leaks who underwent endoscopic management. INTERVENTIONS Temporary placement of MPS (n = 20) or FCSEMSs (n = 20). MAIN OUTCOME MEASUREMENTS Clinical outcomes of endotherapy as well as the technical success, adverse events, need for reinterventions, and prognostic factors for clinical success. RESULTS Endotherapy was possible in all patients. After endotherapy, closure of the leak was accomplished in 13 patients (65%) who received MPS and in 20 patients (100%) who received FCSEMSs (P = .004). The Kaplan-Meier (log-rank) leak-free survival analysis showed a statistically significant difference between the 2 patient populations (χ(2) [1] = 8.30; P < .01) in favor of the FCSEMS group. Use of <3 plastic stents (P = .024), a plastic stent diameter <20F (P = .006), and a high-grade biliary leak (P = .015) were shown to be significant predictors of treatment failure with MPS. The 7 patients in whom placement of MPS failed were retreated with FCSEMSs, resulting in closure of the leaks in all cases. LIMITATIONS Non-randomized design. CONCLUSION In our series, the results of the temporary placement of FCSEMSs for postcholecystectomy refractory biliary leaks were superior to those from the use of MPS. A randomized study is needed to confirm our results before further recommendations.
Collapse
Affiliation(s)
- Jorge Canena
- Center of Gastroenterology, Cuf Infante Santo Hospital-Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal; Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal; Department of Endoscopy, José Joaquim Fernandes Hospital da Unidade Local de Saúde do Baixo Alentejo, Beja, Portugal
| | - Manuel Liberato
- Center of Gastroenterology, Cuf Infante Santo Hospital-Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal
| | - Liliane Meireles
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Inês Marques
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Carlos Romão
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - António Pereira Coutinho
- Center of Gastroenterology, Cuf Infante Santo Hospital-Nova Medical School/Faculty of Medical Sciences, Lisbon, Portugal
| | - Beatriz Costa Neves
- Department of Gastroenterology, Pulido Valente Hospital do Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Pedro Mota Veiga
- Curva de Gauss-Research, Training and Consulting, Canas de Senhorim, Portugal
| |
Collapse
|
24
|
Ljubičić N, Bišćanin A, Pavić T, Nikolić M, Budimir I, Mijić A, Đuzel A. Biliary leakage after urgent cholecystectomy: Optimization of endoscopic treatment. World J Gastrointest Endosc 2015; 7:547-554. [PMID: 25992194 PMCID: PMC4436923 DOI: 10.4253/wjge.v7.i5.547] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 12/30/2014] [Accepted: 03/09/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To investigate the results of endoscopic treatment of postoperative biliary leakage occurring after urgent cholecystectomy with a long-term follow-up.
METHODS: This is an observational database study conducted in a tertiary care center. All consecutive patients who underwent endoscopic retrograde cholangiography (ERC) for presumed postoperative biliary leakage after urgent cholecystectomy in the period between April 2008 and April 2013 were considered for this study. Patients with bile duct transection and biliary strictures were excluded. Biliary leakage was suspected in the case of bile appearance from either percutaneous drainage of abdominal collection or abdominal drain placed at the time of cholecystectomy. Procedural and main clinical characteristics of all consecutive patients with postoperative biliary leakage after urgent cholecystectomy, such as indication for cholecystectomy, etiology and type of leakage, ERC findings and post-ERC complications, were collected from our electronic database. All patients in whom the leakage was successfully treated endoscopically were followed-up after they were discharged from the hospital and the main clinical characteristics, laboratory data and common bile duct diameter were electronically recorded.
RESULTS: During a five-year period, biliary leakage was recognized in 2.2% of patients who underwent urgent cholecystectomy. The median time from cholecystectomy to ERC was 6 d (interquartile range, 4-11 d). Endoscopic interventions to manage biliary leakage included biliary stent insertion with or without biliary sphincterotomy. In 23 (77%) patients after first endoscopic treatment bile flow through existing surgical drain ceased within 11 d following biliary therapeutic endoscopy (median, 4 d; interquartile range, 2-8 d). In those patients repeat ERC was not performed and the biliary stent was removed on gastroscopy. In seven (23%) patients repeat ERC was done within one to fourth week after their first ERC, depending on the extent of the biliary leakage. In two of those patients common bile duct stone was recognized and removed. Three of those seven patients had more complicated clinical course and they were referred to surgery and were excluded from long-term follow-up. The median interval from endoscopic placement of biliary stent to demonstration of resolution of bile leakage for ERC treated patients was 32 d (interquartile range, 28-43 d). Among the patients included in the follow-up (median 30.5 mo, range 7-59 mo), four patients (14.8%) died of severe underlying comorbid illnesses.
CONCLUSION: Our results demonstrate the great efficiency of the endoscopic therapy in the treatment of the patients with biliary leakage after urgent cholecystectomy.
Collapse
|
25
|
Mehmedovic Z, Mehmedovic M, Hasanovic J. A rare case of biliary leakage after laparoscopic cholecystectomy-diagnostic evaluation and nonsurgical treatment: a case report. Acta Inform Med 2015; 23:116-9. [PMID: 26005280 PMCID: PMC4430001 DOI: 10.5455/aim.2015.23.116-119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 04/03/2015] [Indexed: 11/06/2022] Open
Abstract
Although laparoscopic cholecystectomy has become a gold standard in treatment of symptomatic cholelithiasis, it is associated with higher risk of intraoperative lesions and primarily lesions of biliary ducts. In small percentage of cases biliary fistulas occur, most commonly after leakage from cystic duct stump or accessory bile ducts – Luschka’s duct. We report of a patient who had episodes of abdominal pain following routine laparoscopic cholecystectomy for acute calculous gallbladder. Results of conducted diagnostics verify the presence of biliary fistula caused by obstruction of bile pathways by stagnant pus and microcalculi of common bile duct, with development of biloma presumably caused by pressure injection of contrast material during ERCP procedure. Endoscopic sphincterectomy via ERCP enabled healing of formed biliary fistula, whilst continuous percutaneous ultrasound guided drainage of biloma was method of choice in later treatment of our patient. It is important to note that diagnostic evaluation of biliary fistula is very challenging and that timely nonsurgical treatment is of great benefit for patient.
Collapse
Affiliation(s)
- Zlatan Mehmedovic
- Department of General Abdominal Surgery, Clinic for Surgery, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
| | - Majda Mehmedovic
- Department of Gastroenterology and Hepatology, Clinic for Internal Diseases, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
| | - Jasmin Hasanovic
- Department of Hepatobiliopancreatic Surgery, Clinic for Surgery, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
| |
Collapse
|
26
|
Sultan AM, Elnakeeb AM, Elshobary MM, El-Geidi AA, Salah T, El-hanafy EA, Atif E, Hamdy E, Elebiedy GK. Management of post-cholecystectomy biliary fistula according to type of cholecystectomy. Endosc Int Open 2015; 3:E91-8. [PMID: 26134781 PMCID: PMC4440382 DOI: 10.1055/s-0034-1390747] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 09/08/2014] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS A study was undertaken to describe the management of post-cholecystectomy biliary fistula according to the type of cholecystectomy. PATIENTS AND METHODS A retrospective analysis of 111 patients was undertaken. They were divided into open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) groups. RESULTS Of the 111 patients, 38 (34.2 %) underwent LC and 73 (65.8 %) underwent OC. Endoscopic retrograde cholangiopancreatography (ERCP) diagnosed major bile duct injury (BDI) in 27 patients (38.6 %) in the OC group and in 3 patients (7.9 %) in the LC group (P = 0.001). Endoscopic management was not feasible in 15 patients (13.5 %) because of failed cannulation (n = 3) or complete ligation of the common bile duct (n = 12). Endoscopic therapy stopped leakage in 35 patients (92.1 %) and 58 patients (82.9 %) following LC and OC, respectively, after the exclusion of 3 patients in whom cannulation failed (P = 0 0.150). Major BDI was more commonly detected after OC (P < 0.001). Leakage was controlled endoscopically in 77 patients (98.7 %) with minor BDI and in 16 patients (53.3 %) with major BDI (P < 0.001). CONCLUSIONS Major BDI is more common in patients presenting with bile leakage after OC. ERCP is the first-choice treatment for minor BDI. Surgery plays an important role in major BDI. Magnetic resonance cholangiopancreatogrphy (MRCP) should be used before ERCP in patients with bile leakage following OC or converted LC.
Collapse
Affiliation(s)
- Ahmad M. Sultan
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt ,Corresponding author Ahmad Mohammad Sultan, MD Gastro-enterology Surgical CenterMansoura UniversityGehan StreetMansouraEgypt002050223686
| | - Ayman M. Elnakeeb
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
| | - Mohamed M. Elshobary
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
| | - Ahmed A. El-Geidi
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
| | - Tarek Salah
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
| | - Ehab A. El-hanafy
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
| | - Ehab Atif
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
| | - Emad Hamdy
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
| | - Gamal K. Elebiedy
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
| |
Collapse
|
27
|
Dechêne A, Jochum C, Fingas C, Paul A, Heider D, Syn WK, Gerken G, Canbay A, Zöpf T. Endoscopic management is the treatment of choice for bile leaks after liver resection. Gastrointest Endosc 2014; 80:626-633.e1. [PMID: 24796959 DOI: 10.1016/j.gie.2014.02.1028] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 02/27/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Despite improvements in surgical techniques and postoperative patient care, bile leaks still occur postoperatively in as many as 15% of liver resections (LRs) and are associated with high mortality. There is a paucity of outcome data on endoscopic treatment of complex bile leaks. OBJECTIVE The aim of this retrospective study was to evaluate the efficacy of interventional endoscopy in the treatment of bile leaks after LR. DESIGN Retrospective interventional study. SETTING, PATIENTS, AND INTERVENTIONS Sixty patients with bile leaks after LR were treated endoscopically with or without implantation of endoprostheses by using ERCP. The characteristics of LR, effects of surgical and other nonendoscopic treatment measures, clinical and endoscopic presentation of bile leaks, and outcomes after stent placement were recorded. MAIN OUTCOME MEASURE Main outcome measure was resolution of leakage or termination of unsuccessful endoscopic leakage therapy. RESULTS The median age of the observed cohort was 58 years. Sixty-five percent of patients had central and 35% peripheral bile leaks; 55% had resection of an entire hepatic lobe, and 45% underwent segmental resection. The overall success rate of endoscopic therapy was 77%. Although endoscopic therapy was performed in all patients with a mean of 2.6 interventions, 28% underwent additional percutaneous drainage. Success of endoscopic treatment was related to stent implantation. Thirteen patients with unsuccessful endoscopic treatment underwent surgical reintervention, and 1 patient died before surgical intervention. LIMITATIONS No standardized protocol for stent placement due to retrospective nature of the study. Small sample number with uneven distribution of outcome. CONCLUSIONS Endoscopic therapy with sphincterotomy and insertion of endoprostheses is effective, even in large postoperative bile leaks and particularly for leaks proximal to the common hepatic duct. Complete resolution of the leakage often necessitates multiple treatment sessions.
Collapse
Affiliation(s)
- Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Christoph Jochum
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Christian Fingas
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany; Department of General Surgery and Transplantation, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Andreas Paul
- Department of General Surgery and Transplantation, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Dominik Heider
- Department of Bioinformatics, Center for Medical Biotechnology, University of Duisburg-Essen, Essen, Germany
| | - Wing-Kin Syn
- Regeneration and Repair Group, The Institute of Hepatology, London, United Kingdom
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Thomas Zöpf
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany; Department of Internal Medicine and Gastroenterology, Diakonissen-Krankenhaus Rüppurr, Karlsruhe, Germany
| |
Collapse
|
28
|
Mbarushimana S, Morris-Stiff G, Hassn A. CT diagnosis of an iatrogenic bile duct injury. BMJ Case Rep 2014; 2014:bcr-2014-204918. [PMID: 25267805 DOI: 10.1136/bcr-2014-204918] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Bile duct injuries are a recognised complication of cholecystectomy and a number of options exist for their evaluation. A 44-year-old woman presented with a suspected biliary leak 11 days following an open cholecystectomy. Her medical history was significant for biliopancreatic diversion 2 years previously. An ultrasound scan demonstrated a perihepatic collection but no dilation of the biliary tree was observed. The patient's surgical history and the lack of biliary dilation precluded an endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography, and she could not undergo an MR cholangiopancreatography due to claustrophobia. A CT cholangiogram was performed and clarified the location of the injury, facilitating operative identification and repair of the bile duct. CT cholangiography performed as a dynamic procedure is useful as a means of identifying bile duct injuries.
Collapse
Affiliation(s)
| | | | - Ahmed Hassn
- Department of Surgery, Princess of Wales Hospital, Wales, UK
| |
Collapse
|
29
|
Kim KH, Kim TN. Endoscopic management of bile leakage after cholecystectomy: a single-center experience for 12 years. Clin Endosc 2014. [PMID: 24944989 DOI: 10.5946/ce.2014.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND/AIMS Bile leakage is an uncommon but serious complication of cholecystectomy. The aim of this study is to evaluate the efficacy of the endoscopic management of bile leakage after cholecystectomy. METHODS A total of 32 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), because of bile leakage after cholecystectomy, from January 2000 to December 2012 were reviewed retrospectively. The clinical parameters, types of management, and procedure-related complications were documented. RESULTS Most bile leakages presented as percutaneous bile drainage through a Hemovac (68.8%), followed by abdominal pain (18.8%). The sites of bile leaks were the cystic duct stump in 25 patients, intrahepatic ducts in four, liver beds in two, and the common bile duct in one. Biliary stenting with or without sphincterotomy was performed in 22 and eight patients, respectively. Of the four cases of bile leak combined with bile duct stricture, one patient had severe bile duct obstruction and the others had mild stricture. Concerning endoscopic modalities, endoscopic therapy for bile leak was successful in 30 patients (93.8%). Two patients developed transient post-ERCP pancreatitis, which was mild, and both recovered without clinical sequelae. CONCLUSIONS The endoscopic approach of ERCP should be considered a primary modality for the diagnosis and treatment of bile leakage after cholecystectomy.
Collapse
Affiliation(s)
- Kook Hyun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Tae Nyeun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| |
Collapse
|
30
|
Kim KH, Kim TN. Endoscopic management of bile leakage after cholecystectomy: a single-center experience for 12 years. Clin Endosc 2014; 47:248-53. [PMID: 24944989 PMCID: PMC4058543 DOI: 10.5946/ce.2014.47.3.248] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 12/27/2013] [Accepted: 12/27/2013] [Indexed: 01/30/2023] Open
Abstract
Background/Aims Bile leakage is an uncommon but serious complication of cholecystectomy. The aim of this study is to evaluate the efficacy of the endoscopic management of bile leakage after cholecystectomy. Methods A total of 32 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), because of bile leakage after cholecystectomy, from January 2000 to December 2012 were reviewed retrospectively. The clinical parameters, types of management, and procedure-related complications were documented. Results Most bile leakages presented as percutaneous bile drainage through a Hemovac (68.8%), followed by abdominal pain (18.8%). The sites of bile leaks were the cystic duct stump in 25 patients, intrahepatic ducts in four, liver beds in two, and the common bile duct in one. Biliary stenting with or without sphincterotomy was performed in 22 and eight patients, respectively. Of the four cases of bile leak combined with bile duct stricture, one patient had severe bile duct obstruction and the others had mild stricture. Concerning endoscopic modalities, endoscopic therapy for bile leak was successful in 30 patients (93.8%). Two patients developed transient post-ERCP pancreatitis, which was mild, and both recovered without clinical sequelae. Conclusions The endoscopic approach of ERCP should be considered a primary modality for the diagnosis and treatment of bile leakage after cholecystectomy.
Collapse
Affiliation(s)
- Kook Hyun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Tae Nyeun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| |
Collapse
|
31
|
Kim KH, Kim TN. Endoscopic management of bile leakage after cholecystectomy: a single-center experience for 12 years. Clin Endosc 2014. [PMID: 24944989 DOI: 10.5946/ce.2014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND/AIMS Bile leakage is an uncommon but serious complication of cholecystectomy. The aim of this study is to evaluate the efficacy of the endoscopic management of bile leakage after cholecystectomy. METHODS A total of 32 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), because of bile leakage after cholecystectomy, from January 2000 to December 2012 were reviewed retrospectively. The clinical parameters, types of management, and procedure-related complications were documented. RESULTS Most bile leakages presented as percutaneous bile drainage through a Hemovac (68.8%), followed by abdominal pain (18.8%). The sites of bile leaks were the cystic duct stump in 25 patients, intrahepatic ducts in four, liver beds in two, and the common bile duct in one. Biliary stenting with or without sphincterotomy was performed in 22 and eight patients, respectively. Of the four cases of bile leak combined with bile duct stricture, one patient had severe bile duct obstruction and the others had mild stricture. Concerning endoscopic modalities, endoscopic therapy for bile leak was successful in 30 patients (93.8%). Two patients developed transient post-ERCP pancreatitis, which was mild, and both recovered without clinical sequelae. CONCLUSIONS The endoscopic approach of ERCP should be considered a primary modality for the diagnosis and treatment of bile leakage after cholecystectomy.
Collapse
Affiliation(s)
- Kook Hyun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Tae Nyeun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| |
Collapse
|
32
|
Mathioulakis S, Liverakou E, Gourgiotis S, Salemis NS. Choloperitoneum causes extensive coloring of the abdominal wall skin. Am J Emerg Med 2014; 32:1297.e3-4. [PMID: 24746859 DOI: 10.1016/j.ajem.2014.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 03/19/2014] [Accepted: 03/20/2014] [Indexed: 10/25/2022] Open
Abstract
Laparoscopic cholecystectomy, because it is the less invasive surgical procedure, has been established as the procedure of choice for the treatment of patients with symptomatic gallbladder stones. However, bile leakage after laparoscopic cholecystectomy should not be overlooked. It is generally due to a minor biliary complication, although it can sometimes herald a major duct injury. Bile leakage rates of 1.2% to 4.0% in laparoscopic cholecystectomies have been reported, which are higher than the incidence with open cholecystectomies.
Collapse
Affiliation(s)
- Stavros Mathioulakis
- First Surgical Department, 417 NIMTS Military Veterans' Fund Hospital of Athens, Greece
| | - Evangelia Liverakou
- First Surgical Department, 417 NIMTS Military Veterans' Fund Hospital of Athens, Greece
| | - Stavros Gourgiotis
- First Surgical Department, 417 NIMTS Military Veterans' Fund Hospital of Athens, Greece.
| | | |
Collapse
|
33
|
Suo G, Xu A. Clipless minilaparoscopic cholecystectomy: a study of 1,096 cases. J Laparoendosc Adv Surg Tech A 2013; 23:849-54. [PMID: 23980592 DOI: 10.1089/lap.2012.0561] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
PURPOSE Low conversion rate, high safety, and good cosmetic result with less medical cost are chased by all laparoscopic surgeons. We used general laparoscopic instruments and combined with absorbable thread trying to perform a clipless minilaparoscopic cholecystectomy for benign gallbladder patients and got all the above-mentioned results. SUBJECTS AND METHODS From January 2008 to February 2011, 1096 minilaparoscopic cholecystectomies were performed for patients with uncomplicated or complicated benign gallbladder disease by our treatment team. The three-port technique with the help of an electrocautery hook, forceps, and suction was applied for laparoscopy cholecystectomy, and the cystic duct and vessels were ligated by absorbable thread rather than hemostasis clips and Harmonic(®) scalpels (Ethicon, Cincinnati, OH). The operative time, blood loss, subhepatic drain, conversion rate, drainage time, and hospital stay were reviewed and statistically analyzed. RESULTS Our conversion rate was 0.18%, which was much lower than those reported by many studies. The mean operating time was 28 minutes (range, 11-70 minutes). Mean blood loss was 12 mL (range, 5-200 mL). A subhepatic drain was placed in 63 patients, with a mean drainage time of 1.7 days (range, 1-6 days). The mean postoperative hospital stay was 2.5 days (range, 2-7 days). No postoperative bleeding, biliary leakage, intraabdominal infection, umbilical site infection, umbilical incision herniation, biliary duct or bowel injury, or mortality occurred. CONCLUSIONS Minilaparoscopic cholecystectomy using absorbable thread instead of clips and Harmonic scalpels offers a safe, effective, and economical surgical alternative for benign gallbladder patients.
Collapse
Affiliation(s)
- Guangjun Suo
- Department of Digestive Surgery, East Hospital, Tongji University School of Medicine , Shanghai, People's Republic of China
| | | |
Collapse
|
34
|
Necessity of a repeat cholangiogram during biliary stent removal after postcholecystectomy bile leak. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2013; 26:701-4. [PMID: 23061062 DOI: 10.1155/2012/487419] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE To assess the need for repeat endoscopic retrograde cholangiography (ERC) in patients undergoing biliary stent removal after management of postcholecystectomy bile leak. METHODS A retrospective analysis of the Clinical Outcomes Research Initiative endoscopy database at PennState Milton S Hershey Medical Center (Hershey, Pennsylvania, USA) identified all patients referred for ERC with an indication of postcholecystectomy bile leak from January 2001 to June 2010. Baseline demographics, location of bile leak, size of biliary stent placed, duration of stenting, bile leak persistence, and the presence of stone, sludge or strictures on repeat ERC were analyzed. RESULTS A total of 81 patients underwent ERC for management of bile leaks after cholecystectomy. One patient was excluded due to a complete transection of the common bile duct necessitating immediate surgical intervention. Fourteen (17.5%) patients underwent open cholecystectomy, 46 (57.5%) underwent laparoscopic procedures and 10 (12.5%) procedures were converted from a laparoscopic to an open approach intraoperatively. Of the 80 patients, 47 (58.7 %) had a cystic duct leak, 11 (13.7 %) had a right hepatic duct leak, 11 (13.7%) had a common bile duct leak, five (6.2%) had a gallbladder fossa leak, four (5%) had a common hepatic duct leak and the remaining two (2.5%) had a left hepatic duct leak. All 80 patients underwent biliary stenting as part of management for their bile leak. Fifty-seven of the 80 patients (71.2%) had a 10 Fr stent placed, with the remainder undergoing placement of a 7 Fr stent. Seventy-five (93.7%) patients underwent biliary sphincterotomy during the initial ERC. Sixty-nine patients underwent repeat ERC after a mean duration of 8.2 weeks (range 0.4 to 18.5 weeks). Eleven patients had no reviewable records regarding a repeat procedure performed for stent removal. Three patients required an early repeat ERC due to suspicion of cholangitis and, hence, were excluded from the final analysis. Of the 66 patients included in the final analysis, 61 (92.4%) had resolution of their bile leak on repeat ERC. All patients had resolution of their bile leak by the third ERC. Fifteen patients (22.7%) had an abnormality on repeat cholangiography (persistent leak in four, stones in three, sludge in seven, and a combination of leak and stone in one) that required further endoscopic intervention including balloon sweep or additional stenting. CONCLUSION Although the majority of postcholecystectomy bile leaks resolve after biliary stent placement, a sizeable percentage (22.7%) of patients had abnormalities on subsequent cholangiograms that required further intervention. These findings suggest the need for a repeat ERC at the time of biliary stent removal in the management of postcholecystectomy bile leaks.
Collapse
|
35
|
John A, Mattar K, John AS, Khairat M, Al Kaabi S. Therapeutic biliary and pancreatic endoscopy in Qatar- a five year retrospective audit. Qatar Med J 2012; 2012:20-5. [PMID: 25003036 PMCID: PMC3991044 DOI: 10.5339/qmj.2012.2.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Accepted: 12/01/2012] [Indexed: 11/24/2022] Open
Affiliation(s)
- Anil John
- Department of GI/Endoscopy, HMC, Doha, Qatar
| | | | - Anjum Susan John
- Department of Clinical Research, Medical Research Center, HMC, Doha, Qatar
| | | | - Saad Al Kaabi
- Department of Division of GI/Endoscopy, HMC, Doha, Qatar
| |
Collapse
|
36
|
Mischinger HJ, Bernhard G, Cerwenka H, Hauser H, Werkgartner G, Kornprat P, El Shabrawi A, Bacher H. Management of bile duct injury after laparoscopic cholecystectomy*. Eur Surg 2011. [DOI: 10.1007/s10353-011-0060-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
|
37
|
Nallamothu G, Hilden K, Adler DG. Endoscopic retrograde cholangiopancreatography for non-gastroenterologists: what you need to know. Hosp Pract (1995) 2011; 39:70-80. [PMID: 21576899 DOI: 10.3810/hp.2011.04.396] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) represents the most powerful and widely employed platform for pancreaticobiliary interventions. Endoscopic retrograde cholangiopancreatography allows diagnosis and treatment of a broad spectrum of diseases of the pancreaticobiliary tree that are both benign and malignant in nature. Endoscopic retrograde cholangiopancreatography continues to evolve rapidly, and non-gastroenterologists need to understand the indications, contraindications, limitations, and role of ERCP to effectively manage and coordinate the care of patients with known or suspected pancreaticobiliary disease. This article will review the role of ERCP in detail to further an understanding of the procedure as a whole and to assess when referral of a patient for an ERCP or other related test is indicated.
Collapse
Affiliation(s)
- Geetha Nallamothu
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Huntsman Cancer Center, Salt Lake City, UT 84312, USA
| | | | | |
Collapse
|
38
|
Jackson Pratt drain fluid-to-serum bilirubin concentration ratio for the diagnosis of bile leaks. Gastrointest Endosc 2010; 71:99-104. [PMID: 19945100 DOI: 10.1016/j.gie.2009.08.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Accepted: 08/23/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Jackson Pratt (JP) drain fluid bilirubin levels may be assayed in the evaluation of possible bile leaks. Although fluid color and bilirubin level may prompt additional evaluation, there are no reference data available. OBJECTIVE To assess the JP drain fluid-to-serum bilirubin ratio in patients with documented bile leaks. DESIGN Prospective case series. SETTING Tertiary referral center. METHODS Patients referred for ERCP for the management of documented bile leaks with a JP drain in place were included. Demographic data, bile leak etiology, and serum bilirubin levels were recorded. JP drain fluid was sent for color evaluation and bilirubin concentration. Control subjects included both patients after nonbiliary surgery with a JP drain in place and medical patients with ascites undergoing paracentesis. RESULTS JP drain fluid-to-serum bilirubin concentration and fluid color evaluation was performed on 23 patients with documented bile leaks by ERCP and compared with 26 controls (16 surgical and 10 medical). The JP drain fluid/ascites-to-serum bilirubin ratio was significantly higher in those with bile leaks (mean ratio 45.6) compared with combined controls (mean ratio 0.9). Use of a cutoff JP drain fluid-to-serum bilirubin ratio of 5 would be 100% sensitive and specific for the prediction of a bile leak in the selected control group. There was overlap in fluid color evaluation between the groups. LIMITATIONS Controls did not include those with suspected bile leaks and negative technetium 99m-HIDA scintigraphy or ERCP findings. CONCLUSIONS JP drain fluid-to-serum bilirubin concentration ratio greater than 5 seems to be highly sensitive and specific for the detection of a bile leak. Used along with clinical criteria, this ratio could be used to select patients to proceed directly to ERCP.
Collapse
|
39
|
Coelho-Prabhu N, Baron TH. Assessment of need for repeat ERCP during biliary stent removal after clinical resolution of postcholecystectomy bile leak. Am J Gastroenterol 2010; 105:100-5. [PMID: 19773748 DOI: 10.1038/ajg.2009.546] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In patients who have undergone endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement for postcholecystectomy bile leak there is limited evidence to support the repeat ERCP at the time of stent removal. Esophagogastroduodenoscopy (EGD) with biliary stent removal may suffice. The aim of this study was to describe the clinical course of patients who underwent biliary stent placement for a postcholecystectomy bile leak and determine whether repeat ERCP is necessary. METHODS We identified all adult patients who underwent biliary stent placement for postcholecystectomy bile leak from 1 January 1996 to 31 October 2008. Demographic data, cholecystectomy details, and procedural data were collected, specifically focusing on closure of the bile leak. Time to resolution of leak was calculated, up to either the date of the first repeat ERCP that demonstrated no persistent leak or the date of removal of any radiologically placed percutaneous drain, whichever came first. RESULTS Sixty-four patients underwent repeat ERCP with biliary stent removal. The median time to repeat ERCP was 36 days (interquartile range (IQR) 26-48). Fifty-seven (89%) patients had resolved the leak by time of repeat ERCP. Of those in whom the leak had not resolved, 6 had a repeat exam within 14 days of stent placement; 4 of these resolved the leak by day 39. There were no procedure-related complications in the ERCP group. Thirteen patients underwent EGD with stent removal after a median of 29 days (IQR 23-38). None had adverse events, with a median follow-up of 38 months. Overall, the median time to resolution of biliary leak was 33 days (IQR 22-44). Importantly, repeat ERCP altered the management in only one patient in whom bile duct stones were found. CONCLUSIONS Patients with uncomplicated postcholecystectomy bile leak who have clinically resolved their leak do not require cholangiography at the time of stent removal. In these patients, EGD with stent removal at 4-6 weeks seems to be sufficient and significantly less expensive.
Collapse
|
40
|
Zerem E, Omerović S. Minimally invasive management of biliary complications after laparoscopic cholecystectomy. Eur J Intern Med 2009; 20:686-9. [PMID: 19818287 DOI: 10.1016/j.ejim.2009.07.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 07/12/2009] [Accepted: 07/17/2009] [Indexed: 11/16/2022]
Abstract
BACKGROUND We conducted this prospective study to evaluate the efficacy of percutaneous catheter drainage as a minimally invasive treatment in the management of symptomatic bile leak following biliary injuries associated with laparoscopic cholecystectomy. METHODS Twenty two patients with symptomatic bile leak following laparoscopic cholecystectomy underwent percutaneous drainage of the bile collection under ultrasound control. In patients with jaundice and in those with persistent drainage, endoscopic retrograde cholecysto-pancreatography (ERCP) was performed immediately for diagnostic and for therapeutic intervention when appropriate. In other patients, ERCP was performed 4-6 weeks after the discharge from the hospital to document the healing of the leaking site. RESULTS Five patients with jaundice were initially treated by a combination of endoscopic plus percutaneous drainage. One of them required surgical treatment following diagnosis of a major duct injury. The other 17 were treated by percutaneous drainage initially and for 14 of them it was definitive treatment. Three patients required sphincterotomy as additional treatment for stopping the leak. There were no complications related to the percutaneous drainage procedure. CONCLUSIONS Most patients with bile leakage can be managed successfully by percutaneous drainage. If biliary output does not decrease, endoscopy is needed. In patients with jaundice endoscopic diagnostic and therapeutic procedures should be performed immediately.
Collapse
Affiliation(s)
- Enver Zerem
- The University Clinical Center, Tuzla, Bosnia and Herzegovina.
| | | |
Collapse
|
41
|
Shaikh IAA, Thomas H, Joga K, Amin AI, Daniel T. Post-cholecystectomy cystic duct stump leak: a preventable morbidity. J Dig Dis 2009; 10:207-12. [PMID: 19659789 DOI: 10.1111/j.1751-2980.2009.00387.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE While major bile duct injury is the most serious complication following laparoscopic cholecystectomy, bile leak from the cystic duct stump remains the commonest morbidity. This is a retrospective assessment of all patients who had a cholecystectomy over a 5-year period from April 2003 to March 2008. METHODS Data related to bile leakage were obtained from the Unisoft endoscopic retrograde cholangio-pancreatography (ERCP) database. RESULTS Overall 2011 cholecystectomies were performed, of which 488 were done as emergency procedures. Thirteen patients had significant bile leakage, three of which were from accessory ducts, in one the source could not be identified and nine had a cystic duct stump leak (CDSL), which formed the basis of this study. Eight of the nine CDSL patients had successful ERCP and stenting. One had a percutaneous trans-hepatic cholangiography and stenting. CDSL following emergency laparoscopic cholecystectomy was up to threefold higher than after elective procedures. CONCLUSION The CDSL of 0.44% was comparable to the reported incidence in the literature. Endoscopic management remains the treatment of choice. Emergency cholecystectomies seem to have a higher incidence of CDSL.
Collapse
|