Diagnostic and surgical treatment for traumatic bile peritonitis in dogs and cats

OBJECTIVE

To describe short-term outcomes of dogs and cats undergoing surgery for traumatic bile peritonitis.

ANIMALS

13 dogs and 4 cats.

METHODS

Multi-institutional, retrospective study. Medical records from 6 institutions were reviewed for cases of traumatic bile peritonitis between 2006 and 2022. Clinical presentation, additional injuries, surgical treatment, and outcome were recorded.

RESULTS

Trauma occurred a median of 2 (range, 1 to 22) and 4 (range, 1 to 22) days prior to presentation in dogs and cats, respectively. Total bilirubin was increased in 11 of 13 dogs and 2 of 4 cats. Rupture occurred at the common bile duct (CBD) in 10 dogs and 1 cat, gallbladder in 3 dogs, cystic duct in 2 cats, and hepatic duct in 1 dog and 1 cat. The most common surgeries were cholecystoduodenostomy and CBD repair in dogs and cholecystectomy in cats. Eleven of 13 dogs and all cats survived to hospital discharge (88.2% overall survival). Median follow-up in surviving dogs and cats was 35 days (range, 14 to 401) and 30 days (range, 14 to 90), respectively. One dog that underwent cholecystectomy experienced recurrent bile peritonitis 20 days postoperatively. Short-term survival following surgical treatment of traumatic bile peritonitis was excellent and recurrence appears uncommon. The most frequent site of rupture was the CBD in dogs and the cystic duct in cats.

CLINICAL RELEVANCE

Measurement of peritoneal bilirubin should be considered in dogs and cats with peritoneal effusion following trauma. Surgeons should be prepared to identify and address ruptures in locations other than the gallbladder.

Effects of Cystic Duct Margin Involvement on the Survival Rates of Patients With Gallbladder Cancer: A Propensity Score-Matched Case-Control Study

Background In gallbladder cancer (GBC), extrahepatic bile duct (EHBD) resection is selectively performed if gross direct extension or microscopic involvement of the cystic duct margin (CDM) is detected. Although CDM is usually sent for frozen biopsy intraoperatively in most centers, there are no studies regarding the routine use of CDM frozen biopsy irrespective of the tumor location and paucity of literature regarding the impact of CDM status on recurrence-free and overall survival in GBC. The presence of obstructive jaundice in GBC usually indicates the involvement of EHBD or cystic duct-bile duct junction. The present study aimed to analyze the necessity of routine CDM frozen biopsy in patients with resectable GBC without jaundice, regardless of the tumor location. The impact of positive CDM on survival was also evaluated. Methods This retrospective observational case-control study was conducted from May 2009 to March 2021 and included 105 patients with resectable GBC without macroscopic EHBD infiltration and jaundice. Patients were divided into CDM-negative (n=91) and CDM-positive (n=14) groups. Propensity score matching was performed for variables such as performance status, tumor size, tumor-node-metastasis (TNM) stage, and adjuvant chemotherapy. After propensity score matching, 27 patients (CDM-negative=13, CDM-positive=14) were included. The primary outcome was to analyze the role of routine CDM frozen biopsy regardless of tumor location, and secondary outcomes were to study the impact of positive CDM status on survival and evaluate predictive factors for CDM positivity. A subgroup analysis was conducted to assess clinicopathologic characteristics and outcomes of the anatomical location of the tumor. Results Of 105 patients, 91 had negative CDM, and 14 had positive CDM. Among 14 patients with positive CDM, only one patient had a tumor in the fundus/body, and the remaining had a tumor involving the neck. All CDM-positive patients underwent bile duct excision with hepaticojejunostomy. Common bile duct (CBD) involvement was present in 50% of patients with positive CDM in the final histopathological examination. In the matched population, patients with positive CDM had a significantly higher rate of neck tumors (p=0.001). Recurrence-free survival (24 vs. 12 months, p=0.30) and overall survival (24.5 vs. 20 months, p=0.417) were comparable between CDM-negative and CDM-positive groups, respectively. On multivariate analysis, preoperative and intraoperative tumor location were independent predictive factors for CDM positivity. On subgroup analysis, 30 patients had tumor involving the neck of the gallbladder, and the remaining 75 had at the fundus and body of the gallbladder. Neck tumors had inferior recurrence-free survival (17 vs. 30 months, p=0.012) and overall survival (24 vs. 36 months, p=0.048) compared to non-neck tumors. Conclusions Routine use of CDM frozen analysis in patients with resectable GBC without jaundice, regardless of tumor location, can be avoided. It can be selectively preferred in patients with GBC involving the neck since tumor location is found to be an independent predictive factor for CDM positivity. Positive CDM has comparable survival outcomes to negative CDM, providing a similar R0 resection rate and tumor stage. However, neck tumors have a worse prognosis than non-neck tumors.

Hotspots and difficulties of biliary surgery in older patients

ABSTRACT

With the accelerated aging society in China, the incidence of biliary surgical diseases in the elderly has increased significantly. The clinical characteristics of these patients indicate that improving treatment outcomes and realizing healthy aging are worthy of attention. How to effectively improve the treatment effect of geriatric biliary surgical diseases has attracted widespread attention. This paper reviews and comments on the hotspots and difficulties of biliary surgery in older patients from six aspects: (1) higher morbidity associated with an aging society, (2) prevention and control of pre-operative risks, (3) extending the indications of laparoscopic surgery, (4) urgent standardization of minimally invasive surgery, (5) precise technological progress in hepatobiliary surgery, and (6) guarantee of peri-operative safety. It is of great significance to fully understand the focus of controversy, actively make use of its favorable factors, and effectively avoid its unfavorable factors, for further improving the therapeutic effects of geriatric biliary surgical diseases, and thus benefits the vast older patients with biliary surgical diseases. Accordingly, a historical record with the highest age of 93 years for laparoscopic transcystic common bile duct exploration has been created by us recently.

Application of a nurse-led transitional care programme for patients discharged with T-tubes after biliary surgery

AIM

Nurse-led transitional care programmes (TCPs) have been shown to facilitate patient recovery in several illness settings, but its role among patients discharged with T-tubes remains uncertain. The aim of the study was to investigate the effects of a nurse-led TCP among patients discharged with T-tubes.

DESIGN

This retrospective cohort study was conducted at a tertiary medical centre.

METHODS

From January 2018 to December 2020, a total of 706 patients discharged with T-tubes after biliary surgery were included in the study. Patients were divided into a TCP group (n = 255) and a control group (n = 451) based on whether they participated in a TCP. The baseline characteristics, discharge readiness, self-care ability, transitional care quality and quality of life (QoL) were compared between the groups.

RESULTS

Self-care ability and transitional care quality were significantly higher in the TCP group. Patients in the TCP group also exhibited improved QoL and satisfaction. The results suggest that the incorporation of a nurse-led TCP among patients discharged with T-tubes after biliary surgery is feasible and effective. No Patient or Public Contribution.

Incidental Finding of Gallbladder Torsion During Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is a common general surgery procedure, with over a million laparoscopic cholecystectomies performed in the United States annually. A rare presentation, which may be encountered incidentally during surgery, is torsion of the gallbladder. Gallbladder torsion is encountered in 0.01% of all patients with acute cholecystitis. It should be considered in the differential diagnosis of elderly female patients presenting with symptoms of acute or chronic cholecystitis.  In this case report, we discuss the incidental finding of gallbladder torsion during laparoscopic cholecystectomy in an 82-year-old female admitted to the hospital with symptoms of cholecystitis. Preoperative CT imaging revealed a chronic, large hiatal hernia and a dilated gallbladder containing heterogeneous densities, possibly related to sludge. During the operation, a necrotic, torsed gallbladder and long cystic duct were found. A laparoscopic cholecystectomy was performed and the remainder of the patient's hospital course was uncomplicated. Intraoperatively, our patient was found to have torsion of the gallbladder. Preoperative lab values revealed mild hyponatremia, hypokalemia, and hypochloremia with normal liver enzymes, bilirubin, and alkaline phosphatase levels. This is consistent with documented cases, as typically the biliary tree is not obstructed. Additionally, preoperative imaging rarely reveals the diagnosis. Prompt detorsion and cholecystectomy should be performed to prevent gangrene and perforation. Gallbladder torsion can result in perforation if not quickly identified and treated. We recommend prompt laparoscopic detorsion and cholecystectomy to prevent perforation.

Risk factors of delayed recovery from general anesthesia in patients undergoing radical biliary surgery: What can we prevent

Delayed recovery (DR) is very commonly seen in the patients undergoing laparoscopic radical biliary surgery, we aimed to investigate the potential risk factors of DR in the patients undergoing radical biliary surgery, to provide evidences into the management of DR.Patients who underwent radical biliary surgery from January 1, 2018 to August 31, 2020 were identified. The clinical characteristics and treatment details of DR and no-DR patients were compared and analyzed. Multivariable logistic regression analyses were conducted to identify the potential influencing factors for DR in patients with laparoscopic radical biliary surgery.We included a total of 168 patients with laparoscopic radical biliary surgery, the incidence of postoperative DR was 25%. There were significant differences on the duration of surgery, duration of anesthesia, and use of intraoperative combined sevoflurane inhalation (all P < .05), and there were not significant differences on American Society of Anesthesiologists, New York Heart Association, tumor-lymph node- metastasis, and estimated blood loss between DR group and control group (all P > .05). Multivariable logistic regression analyses indicated that age ≥70 years (odd ratio [OR] 1.454, 95% confidence interval [CI] 1.146-1.904), body mass index ≥25 kg/m2 (OR 1.303, 95% CI 1.102-1.912), alcohol drinking (OR 2.041, 95% CI 1.336-3.085), smoking (OR 1.128, 95% CI 1.007-2.261), duration of surgery ≥220 minutes (OR 1.239, 95% CI 1.039-1.735), duration of anesthesia ≥230 minutes (OR 1.223, 95% CI 1.013-1.926), intraoperative combined sevoflurane inhalation (OR 1.207, 95% CI 1.008-1.764) were the independent risk factors for DR in patients with radical biliary surgery (all P < .05).It is clinically necessary to take early countermeasures against various risk factors to reduce the occurrence of DR, and to improve the prognosis of patients.

The Role of Simulation in Attaining Proficiency in Minimally Invasive Hepatopancreatobiliary Surgery

The implementation of robotic surgery in the field of hepato-pancreato-biliary (HPB) has been a slow but significant process. HPB procedures offer a unique challenge when for new technologies, as the surgeries themselves are complex, with long learning curves. Yet the benefits of the robotic approach for this patient population are notable: decreased length of stay, blood loss, postoperative complications, and improving quality of life. The use of robotic simulation focused curriculum plays a crucial role in mentoring experienced surgeons and surgical trainees. Although further study remains, early studies suggest a structured simulation curriculum decreases time, technical errors, and improves proficiency, ultimately leading to a more expedited and safe implementation of robotic techniques in the HPB field.

Surgical Management of Feline Extrahepatic Biliary Tract Diseases

Extrahepatic biliary obstruction occurs infrequently in cats. Pathophysiology of biliary obstruction is characterized by cholestasis, obstruction, inflammation, and exudation. Clinical signs and laboratory examination findings are nonspecific. Ultrasonographic examination of the biliary tract aids significantly in diagnosis. The aims of feline biliary surgery are to determine the underlying cause and extent of the obstruction, restore bile flow to the gastrointestinal tract, and prevent bile leakage and subsequent peritonitis. Surgical techniques to restore bile flow and decompress the biliary distension include cholecystostomy tube placement and choledochal stenting, cholecystectomy, choledochotomy, and biliary diversion procedures. Surgical management of extrahepatic biliary obstruction carries a fair to guarded prognosis. Cats undergoing biliary diversion procedures have poorer outcomes than those undergoing nondiversion procedures. Cats with neoplastic involvement have significantly shorter lives than those with inflammatory involvement.

Clip as Nidus for Choledocholithiasis after Cholecystectomy-Literature Review

Background and Objectives

Foreign material in the biliary tree may serve as a nidus for stone formation and would usually present as choledocholithiasis with jaundice or cholangitis. Overall it is a rare occurrence, but there are many anecdotal reports of ingested matter or surgical material such as suture or clips causing biliary stones. Especially interesting are the cases in which there is migration of a metallic clip used in laparoscopic cholecystectomy. Cholecystectomy is such a common operation that although the phenomenon is rare, it is important because it is preventable, and as such a review of the topic seems worthwhile.

Methods

The available literature was searched using the EMBASE and Ovid databases and reviewed. The various devices and sutures used to occlude the cystic duct in laparoscopic cholecystectomy are discussed with reference to their safety.

Results and Conclusion

We found that the harmonic scalpel is a reasonable alternative with minimal complications but is however limited by cost. Electrosurgical vessel-sealing, ultrasonic shears, absorbable sutures such as endoloops (PDS), and polymer clips as well absorbable magnesium-calcium-zinc alloy clip are discussed.

Fifty-year history of biliary surgery

There has been enormous progress in the surgical treatment of biliary tract cancers in the past 50 years. In preoperative management, biliary drainage methods have changed from percutaneous transhepatic biliary drainage to endoscopic nasobiliary drainage, while the advent of multidetector-row computed tomography in imaging diagnostics now enables visualization of three-dimensional anatomy, extent of cancer progression, and hepatic segment volume. Portal vein embolization has also greatly improved the safety of extended hepatectomy, and indication of extended hepatectomy can now be objectively determined with a combination of the indocyanine green test and computed tomography volumetry. In terms of surgery, combined resection and reconstruction of the portal vein and/or hepatic artery can now be safely carried out at specialized centers. Further, long-term survival can be attained with combined vascular resection if R0 resection can be achieved, even in locally advanced cancer. Hepatopancreatoduodenectomy, combined major hepatectomy with pancreatoduodenectomy, should be aggressively carried out for laterally advanced cholangiocarcinoma, whereas its indication for advanced gallbladder cancer should be carefully evaluated. Japanese surgeons have made a significant contribution to the progression of extended surgeries such as combined vascular resection and hepatopancreatoduodenectomy for biliary tract cancer.

Risk factors for recurrence of common bile duct stones after endoscopic biliary sphincterotomy

Objective

Late complications after endoscopic biliary sphincterotomy (EST) include stone recurrence, but no definite risk factors for recurrence have been established. This study was performed to identify the predictors of recurrence and evaluate the clinical outcomes of EST for common bile duct stones.

Methods

In total, 345 eligible patients who successfully underwent EST were evaluated and followed up. Statistical analysis was performed on patients with recurrence or who had undergone at least 6 months of reliable follow-up to detect the risk factors for recurrence.

Results

A total of 57 patients (16.52%) developed recurrence of common bile duct stones. The median length of time until recurrence was 10.25 months (range, 6–54.4 months). Univariate analyses showed that the following factors were associated with recurrence: cholecystectomy prior to EST, prior biliary tract surgery, periampullary diverticulum, diameter of the common bile duct (>15 vs. ≤15 mm), quantity of stones, complete stone removal at the first session, and lithotripsy. Multivariate analysis identified two independent risk factors for recurrence: previous biliary tract surgery and lithotripsy.

Conclusions

EST for common bile duct stones is safe as indicated by patients’ long-term outcomes. Patients with a history of biliary surgery or lithotripsy are more prone to recurrence.

An evaluation of electrosurgical vessel-sealing devices in biliary tract surgery in a porcine model

OBJECTIVES

The purpose of this study was to evaluate two electrosurgical vessel-sealing devices in biliary surgery.

METHODS

Porcine common bile ducts (CBDs) were sealed with two electrosurgical devices, an electrothermal bipolar vessel-sealing device (EBVS) and ultrasonic coagulation shears. Acute study animals underwent surgical bile duct sealing followed by immediate burst pressure testing. Chronic study animals were maintained for 1 week postoperatively and then tested.

RESULTS

The seal failure rate in the acute study was 50% for both the EBVS device and shears, and 0% for the laparoscopic surgical clip device used as a control. The latter had significantly higher burst pressures (646.2 ± 281.8 mmHg; P = 0.006) than the EBVS device (97.6 ± 86.6 mmHg) and shears (71.7 ± 89.3 mmHg). No significant difference in burst pressures was noted between the EBVS device and shears (97.6 ± 86.6 mmHg vs. 71.7 ± 89.3 mmHg). In the chronic study, obvious bile leaks occurred in one of four pigs (25%) in the EBVS device subgroup and two of four pigs (50%) in the shears subgroup. The average proximal CBD pressure in seven pigs was 16.1 ± 4.1 mmHg. The average chronic burst pressure in the control subgroup was 1088.0 ± 922.6 mmHg.

CONCLUSIONS

Given the high rates of failure of the EBVS device and the shears in consistently sealing biliary ducts, we do not recommend their routine use in biliary surgery.

Resection of hilar cholangiocarcinoma with left hepatectomy after pre-operative embolization of the proper hepatic artery

BACKGROUND

Right or right-extended hepatectomy including the caudate lobe is the most common treatment for hilar cholangiocarcinoma (HC). A 5-year survival of up to 60% can be achieved using this procedure if R0-resection is obtained. However, for some patients a left-sided liver resection is necessary to obtain radical resection. The close relationship between the right hepatic artery and the HC in these patients frequently limits the ability to achieve a radial R0-resection without difficult vascular reconstruction. The aim of the present study was to describe the outcome of patients who underwent pre-operative embolization of the proper hepatic artery in an effort to induce development of arterial collaterals thus allowing the resection of the proper and right hepatic artery without vascular reconstruction.

METHODS

In patients presenting with HC who were considered to require a left hepatic lobectomy and in whom pre-operative work up revealed possible tumour invasion of the right hepatic artery, transcatheter arterial embolization (TAE) of the proper hepatic artery or the left and right hepatic arteries was performed. Three weeks later, a left-sided hepatectomy with resection of all portal structures except the portal vein was performed.

RESULTS

In six patients, pre-operative embolization of the proper hepatic artery was performed. Almost instantaneously in all six patients arterial flow signals could be detected in the liver using Doppler ultrasonography. No patient died peri-operatively. In all six patients an R0 radial resection was achieved and in three an R0 proximal transection margin was obtained. All post-operative complications were managed successfully using percutaneous drainage procedures. No patient developed local recurrence and two patients remain disease free more than 7 years after surgery.

SUMMARY

After pre-operative embolization of the proper hepatic artery, resection of the HC with left hepatectomy is a promising new approach for these technically demanding patients, giving them the chance of a cure.