Liver resection for the treatment of post-cholecystectomy biliary stricture with vascular injury

Liver transplantation for iatrogenic bile duct injury: a systematic review

BACKGROUND

Bile duct injury (BDI) is an infrequent but serious complication of cholecystectomy, often with life-changing consequences. Liver transplantation (LT) may be required following severe BDI, however given the rarity, few large studies exist to guide management for complex BDI.

METHODS

A systematic review was performed to assess post-operative complications, 30-day mortality, retransplant rate and 1-year and 5-year survival following LT for BDI in Medline, EMBASE, Web of Science or Cochrane Clinical Trials Database.

RESULTS

Seven articles met inclusion criteria, describing 179 patients that underwent LT for BDI. Secondary biliary cirrhosis (SBC) was the main indication for LT (82.2% of patients). Median model for end-stage liver disease (MELD) scores at time of LT ranged from 16 to 20.5. Median 30-day mortality was 20.0%. The 1-year and 5-year survival ranges were 55.0-84.3% and 30.0-83.3% respectively, and the overall retransplant rate was 11.5%.

CONCLUSION

BDI is rarely indicated for LT, predominantly for SBC following multiple prior interventions. MELD scores poorly reflect underlying morbidity, and exception criteria for waitlisting may avoid prolonged LT waiting times. 30-day mortality was higher than for non-BDI indications, with comparable long term survival, suggesting that LT remains a viable but high risk salvage option for severe BDI.

Surgical reconstruction of major bile duct injuries: Long-term results and risk factors for restenosis

BACKGROUND

A single-institution retrospective analysis was undertaken to assess long-term results of definitive surgical reconstruction for major bile duct injuries and risk factors for restenosis.

METHODS

Patients treated between January 1995 and October 2020 were reviewed retrospectively. The primary outcome measure was patency.

RESULTS

Of 417 patients referred to a tertiary center, 290 (69.5%) underwent surgical reconstruction; mostly in the form of a hepaticojejunostomy (n = 281, 96.8%). Major liver resection was undertaken in 18 patients (6.2%). There were 7 postoperative deaths (2.4%). Patency was achieved in 97.4% of primary repairs and 88.8% of re-repairs. Primary patency at three months (including postoperative deaths and stents removed afterwards) in primary repairs was significantly higher than secondary patency attained during the same period in re-repairs (89.3% vs 76.5%, p < 0.01). The actuarial primary patency was also significantly higher compared to the actuarial secondary patency 10 years after reconstruction (86.7% vs 70.4%, p = 0.001). Vascular disruption was the only independent predictor of loss of patency after reconstruction (OR 7.09, 95% CI 3.45-14.49, p < 0.001), showing interaction with injuries at or above the biliary bifurcation (OR 9.52, 95% CI 2.56-33.33, p < 0.001).

CONCLUSIONS

Long-term outcome of surgical reconstruction for major bile duct injuries was superior in primary repairs compared to re-repairs. Concomitant vascular injury was independently associated with loss of patency requiring revision.

Right posterior bile duct stricture after central bisectionectomy or anterior sectionectomy

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.

Timing of surgical repair of bile duct injuries after laparoscopic cholecystectomy: A systematic review

BACKGROUND

The surgical management of bile duct injuries (BDIs) after laparoscopic cholecystectomy (LC) is challenging and the optimal timing of surgery remains unclear. The primary aim of this study was to systematically evaluate the evidence behind the timing of BDI repair after LC in the literature.

AIM

To assess timing of surgical repair of BDI and postoperative complications.

METHODS

The MEDLINE, EMBASE, and The Cochrane Library databases were systematically screened up to August 2021. Risk of bias was assessed via the Newcastle Ottawa scale. The primary outcomes of this review included the timing of BDI repair and postoperative complications.

RESULTS

A total of 439 abstracts were screened, and 24 studies were included with 15609 patients included in this review. Of the 5229 BDIs reported, 4934 (94%) were classified as major injury. Timing of bile duct repair was immediate (14%, n = 705), early (28%, n = 1367), delayed (28%, n = 1367), or late (26%, n = 1286). Standardization of definition for timing of repair was remarkably poor among studies. Definitions for immediate repair ranged from < 24 h to 6 wk after LC while early repair ranged from < 24 h to 12 wk. Likewise, delayed (> 24 h to > 12 wk after LC) and late repair (> 6 wk after LC) showed a broad overlap.

CONCLUSION

The lack of standardization among studies precludes any conclusive recommendation on optimal timing of BDI repair after LC. This finding indicates an urgent need for a standardized reporting system of BDI repair.

Hepatectomy after bile duct injury: a systematic review

BACKGROUND

Bile duct injury (BDI) after cholecystectomy can lead to recurrent cholangitis, even after biliary reconstruction. This necessitates hepatectomy in a minority of patients. A systematic review was conducted, summarizing the pattern of biliary injury sustained in this group and their outcomes after hepatectomy.

METHODS

A literature search included the MEDLINE, EMBASE, PubMed and Cochrane libraries. Retrospective cohort studies describing outcomes for hepatectomy after BDI, and the nature of the antecedent BDI, published between 1999 and 2019, were selected.

RESULTS

Eight articles described a cohort of 2110 patients with BDI. Of these, 84 underwent hepatectomy. Complex vasculo-biliary injuries had been sustained in most cases. The mean time to hepatectomy was between 26 and 224 months after BDI. A right hepatectomy was performed in 67-89% of cases. Post hepatectomy, intra-abdominal infection (range 0-50%) and bile leaks (range 0-45%) occurred variably. Mortality occurred in three series. Nineteen percent of patients (16 of 84) developed recurrent symptoms at follow up.

CONCLUSION

Hepatectomy after bile duct injury is an uncommon procedure and represents a salvage strategy when vasculo-biliary injury happens. Liver resection leads to resolution of symptoms in the majority of the cases however postoperative bile leaks and intra-abdominal infection are common.

Total Hilar Exposure Maneuver for Repair of Complex Bile Duct Injury

The reconstruction of high-level bile duct injury is challenging because exposure of the hilar area is limited and sometimes inaccessible by the Hepp-Couinaud approach. We describe a maneuver for total hilar exposure to perform complex bile duct injury reconstruction. After adhesions surrounding the liver are divided, intraoperative ultrasonography is used to delineate the hilar and intrahepatic biliary anatomy. Surgical exposure of the biliary system is achieved by our maneuver, which consists of four steps: (1) identification of landmark structures, such as the base of the umbilical fissure, the inferior edge of segment 4b, the cystic-hilar plate junction, and the right anterior portal pedicle; (2) lowering of the hilar plate; (3) hepatotomy along the right anterior pedicle; and (4) connection of the hepatotomy to the base of segment 4b. This maneuver allows the liver to be flipped upward, which facilitates clear exposure of the hilar duct and preserves the liver parenchyma. The anterior parts of the right and left hepatic duct are then opened, a wide-hepaticojejunostomy anastomosis is achieved for biliary reconstruction, and a jejunal subcutaneous limb is created. We used this maneuver for treating complex bile duct injury in six cases; none of the patients has died, and two had Clavien-Dindo grade III complications, including surgical site infection and intra-abdominal collection. The total hilar exposure maneuver is thus feasible and safe. It provides excellent exposure of both hepatic ducts and is a good surgical alternative to the Hepp-Couinaud approach in cases of high-level injury.

Recurrent pyogenic liver abscess after pancreatoduodenectomy caused by common hepatic artery injury: A case report

BACKGROUND

Pancreaticoduodenectomy (PD) has been increasingly performed as a safe treatment option for periampullary malignant and benign disorders. However, the operation may result in significant postoperative complications. Here, we present a case that recurrent pyogenic liver abscess after PD is caused by common hepatic artery injury in atypical celiac axis anatomy.

CASE SUMMARY

A 56-year-old man with a 1-d history of fever and shivering was diagnosed with hepatic abscess. One year and five months ago, he underwent PD at a local hospital to treat chronic pancreatitis. After the operation, the patient had recurrent intrahepatic abscesses for 4 times, and the symptoms were relieved after percutaneous transhepatic cholangial drainage combining with anti-inflammatory therapy in the local hospital. Further examination showed that the recurrent liver abscess after PD was caused by common hepatic artery injury due to abnormal abdominal vascular anatomy. The patient underwent percutaneous drainage but continued to have recurrent episodes. His condition was eventually cured by right hepatectomy. In this case, preoperative examination of the patient’s anatomical variations with computed tomography would have played a pivotal role in avoiding arterial injuries.

CONCLUSION

A careful computed tomography analysis should be considered mandatory not only to define the operability (with radical intent) of PD candidates but also to identify atypical arterial patterns and plan the optimal surgical strategy.

Management of Postcholecystectomy Complications

Cholecystectomy is one of the most common general surgery procedures performed worldwide. Complications include bile duct injury, strictures, bleeding, infection/abscess, retained gallstones, hernias, and postcholecystectomy syndrome. Obtaining a critical view of safety and following the other tenets of the Safe Cholecystectomy Task Force will aid in the prevention of bile duct injury and other morbidity associated with cholecystectomy.

Post-operative biliary strictures

Post-operative biliary stricture is a cumbersome condition, secondary to biliary or vascular damage. Its risk factors include biliary or vascular anatomical variants, local inflammation, and poor surgical expertise. Intra-operative diagnosis is difficult, and in most cases, patients present with obstructive symptoms within a few weeks. Magnetic resonance cholangiography is a pivotal test to confirm the clinical picture, to study the level of the damage, and to guide treatment. Nowadays, endoscopic stenting is the first-line treatment in most centers. Multi-stenting treatment achieves long-term clinical success for more than 90% of patients, however multiple procedures are needed. In order to optimize healthcare provider costs, shorter duration endotherapies with covered metal stents are under evaluation. Radiological and surgical approaches are considered in the event of endoscopy failure.

Bile Duct Injury Repairs after Laparoscopic Cholecystectomy: A Five-Year Experience in a Highly Specialized Community Hospital

Bile duct injury represents a complication after laparoscopic cholecystectomy, impairing quality of life and resulting in subsequent litigations. A five-year experience of bile duct injury repairs in 52 patients at a community hospital was reviewed. Twenty-nine were female, and the median age was 51 years (range, 20–83 years). Strasberg classification identified injuries as Type A (23), B (1), C (1), D (5), E1 (5), E2 (6), E3 (4), E4 (6), and E5 (1). Resolution of the bile duct injury and clinical improvement represent main postoperative outcome measures in our study. The referral time for treatment was within 4 to 14 days of the injury. Type A injury was treated with endobiliary stent placement. The remaining patients required T-tube placement (5), hepaticojejunostomy (20), and primary anastomosis (4). Two patients experienced bile leak after hepaticojejunostomy and were treated and resolved with percutaneous transhepatic drainage. At a median follow-up of 36 months, two patients (Class E4) required percutaneous balloon dilation and endobiliary stent placement for anastomotic stricture. The success of biliary reconstruction after complicated laparoscopic cholecystectomy can be achieved by experienced biliary surgeons with a team approach in a community hospital setting.