Orthotopic liver transplantation is the definitive treatment for end-stage liver disease and hepatocellular carcinomas.Biliary complications are the most common complications seen after transplantation,with an inciden...Orthotopic liver transplantation is the definitive treatment for end-stage liver disease and hepatocellular carcinomas.Biliary complications are the most common complications seen after transplantation,with an incidence of 10-25%.These complications are seen both in deceased donor liver transplant and living donor liver transplant.Endoscopic treatment of biliary complications with endoscopic retrograde cholangiopancreatography(commonly known as ERCP)has become a mainstay in the management post-transplantation.The success rate has reached 80%in an experienced endoscopist's hands.If unsuccessful with ERCP,percutaneous transhepatic cholangiography can be an alternative therapy.Early recognition and treatment has been shown to improve morbidity and mortality in post-liver transplant patients.The focus of this review will be a learned discussion on the types,diagnosis,and treatment of biliary complications post-orthotopic liver transplantation.展开更多
The incidence of biliary injury after laparoscopic cholecystectomy(LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated w...The incidence of biliary injury after laparoscopic cholecystectomy(LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include:(1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations;(2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury;(3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy;(4) proper gallbladder retraction;(5) safe use of various energy devices;(6) understanding the critical view of safety, including its doublet view and documentation;(7) awareness of various error traps(e.g., fundus first technique);(8) use of various bailout strategies(e.g., subtotal cholecystectomy) in difficult gallbladder cases;(9) use of intraoperative imaging techniques(e.g., intraoperative cholangiogram) to ascertain correct anatomy; and(10) understanding the concept of time-out.Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.展开更多
AIM: To elucidate the impact of various donor recipient and transplant factors on the development of biliary complications after liver transplantation.METHODS: We retrospectively reviewed 200 patients of our newly est...AIM: To elucidate the impact of various donor recipient and transplant factors on the development of biliary complications after liver transplantation.METHODS: We retrospectively reviewed 200 patients of our newly established liver transplantation(LT) program, who received full size liver graft. Biliary reconstruction was performed by side-to-side(SS), end-to-end(EE) anastomosis or hepeaticojejunostomy(HJ). Biliary complications(BC), anastomotic stenosis, bile leak, papillary stenosis, biliary drain complication, ischemic type biliary lesion(ITBL) were evaluated by studying patient records, corresponding radiologic imaging and reports of interventional procedures [e.g., endoscopic retrograde cholangiopancreatography(ERCP)]. Laboratory results included alanine aminotransferase(ALT), gammaglutamyltransferase and direct/indirect bilirubin with focus on the first and fifth postoperative day, six weeks after LT. The routinely employed external bile drain was examined by a routine cholangiography on the fifth postoperative day and six weeks after transplantation as a standard procedure, but also whenever clinically indicated. If necessary, interventional(e.g., ERCP) or surgical therapy was performed. In case of biliary complication, patients were selected, assigned to different complication-groups and subsequently reviewed in detail. To evaluate the patients outcome, we focussed on appearance of postoperative/post-interventional cholangitis, need for rehospitalisation, retransplantation, ITBL or death caused by BC.RESULTS: A total of 200 patients [age: 56(19-72), alcoholic cirrhosis: n = 64(32%), hepatocellular carcinoma: n = 40(20%), acute liver failure: n = 23(11.5%), cryptogenic cirrhosis: n = 22(11%), hepatitis B virus /hepatitis C virus cirrhosis: n = 13(6.5%), primary sclerosing cholangitis: n = 13(6.5%), others: n = 25(12.5%) were included. The median follow-up was 27 mo until June 2015. The overall biliary complication rate was 37.5%(n = 75) with anastomotic strictures(AS): n = 38(19%), bile leak(BL): n = 12(6%展开更多
BACKGROUND Laparoscopic cholecystectomy(LC)combined with laparoscopic common bile duct(CBD)exploration(LCBDE)is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm.However,for pat...BACKGROUND Laparoscopic cholecystectomy(LC)combined with laparoscopic common bile duct(CBD)exploration(LCBDE)is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm.However,for patients with small CBD(CBD diameter≤8 mm),endoscopic sphincterotomy remains the preferred treatment at present,but it also has some drawbacks associated with a series of complications,such as pancreatitis,hemorrhage,cholangitis,and duodenal perforation.To date,few studies have been reported that support the feasibility and safety of LCBDE for choledocholithiasis with small CBD.AIM To investigate the feasibility and safety of LCBDE for choledocholithiasis with small CBD.METHODS A total of 257 patients without acute cholangitis who underwent LC+LCBDE for cholecystolithiasis from January 2013 to December 2018 in one institution were reviewed.The clinical data were retrospectively collected and analyzed.According to whether the diameter of CBD was larger than 8 mm,257 patients were divided into large CBD group(n=146)and small CBD group(n=111).Propensity score matching(1:1)was performed to adjust for clinical differences.The demographics,intraoperative data,short-term outcomes,and long-term follow-up outcomes for the patients were recorded and compared.RESULTS In total,257 patients who underwent successful LC+LCBDE were enrolled in the study,146 had large CBD and 111 had small CBD.The median follow-up period was 39(14-86)mo.For small CBD patients,the median CBD diameter was 0.6 cm(0.2-2.0 cm),the mean operating time was 107.2±28.3 min,and the postoperative bile leak rate,rate of residual CBD stones(CBDS),CBDS recurrence rate,and CBD stenosis rate were 5.41%(6/111),3.60%(4/111),1.80%(2/111),and 0%(0/111),respectively;the mean postoperative hospital stay was 7.4±3.6 d.For large CBD patients,the median common bile duct diameter was 1.0 cm(0.3-3.0 cm),the mean operating time was 115.7±32.0 min,and the postoperative bile leak rate,rate of residual CBDS,CBDS recurrence rate,and CBD stenosis rate were 5.41%(9展开更多
BACKGROUND: Iatrogenic bile duct injury continues to be an important clinical problem, resulting in serious morbidity, and occasional mortality, to patients. The ease of management, operative risk, and outcome of bile...BACKGROUND: Iatrogenic bile duct injury continues to be an important clinical problem, resulting in serious morbidity, and occasional mortality, to patients. The ease of management, operative risk, and outcome of bile duct injuries vary considerably, and are highly dependent on the type of injury and its location. This article reviews the various classification systems of bile duct injury. DATA SOURCES: A Medline, PubMed database search was performed to identify relevant articles using the keywords 'bile duct injury', 'cholecystectomy', and 'classification'. Additional papers were identified by a manual search of the references from the key articles. RESULTS: Traditionally, biliary injuries have been classified using the Bismuth's classification. This classification, which originated from the era of open surgery, is intended to help the surgeons to choose the appropriate technique for the repair, and it has a good correlation with the final outcome after surgical repair. However, the Bismuth's classification does not encompass the whole spectrum of injuries that are possible. Bile duct injury during laparoscopic cholecystectomy tends to be more severe than those with open cholecystectomy. Strasberg's classification made Bismuth's classification much more comprehensive by including various other types of extrahepatic bile duct injuries. Our group, Bergman et al, Neuhaus et al, Csendes et al, and Stewart et al have also proposed other classification systems to complement the Bismuth's classification. CONCLUSIONS: None of the classification system is universally accepted as each has its own limitation. Hopefully, a universally accepted comprehensive classification system will be published in the near future.展开更多
Liver transplantation is the optimal treatment for many patients with advanced liver disease, including decompensated cirrhosis, hepatocellular carcinoma and acute liver failure. Organ shortage is the maindeterminant ...Liver transplantation is the optimal treatment for many patients with advanced liver disease, including decompensated cirrhosis, hepatocellular carcinoma and acute liver failure. Organ shortage is the maindeterminant of death on the waiting list and hence living donor liver transplantation(LDLT) assumes importance. Biliary complications are the most common post operative morbidity after LDLT and occur due to anatomical and technical reasons. They include biliary leaks, strictures and cast formation and occur in the recipient as well as the donor. The types of biliary complications after LDLT along with their etiology, presenting features, diagnosis and endoscopic and surgical management are discussed.展开更多
Biliary complications(BC) currently represent a major source of morbidity after liver transplantation. Although refinements in surgical technique and medical therapy have had a positive influence on the reduction of p...Biliary complications(BC) currently represent a major source of morbidity after liver transplantation. Although refinements in surgical technique and medical therapy have had a positive influence on the reduction of postoperative morbidity, BC affect 5% to 25% of transplanted patients. Bile leak and anastomotic strictures represent the most common complications. Nowadays, a multidisciplinary approach is required to manage such complications in order to prevent liver failure and retransplantation.展开更多
BACKGROUND: Orthotopic liver transplantation has been widely used in patients with end-stage liver disease within the last two decades. However, the prevalence of biliary complications after liver transplantation rema...BACKGROUND: Orthotopic liver transplantation has been widely used in patients with end-stage liver disease within the last two decades. However, the prevalence of biliary complications after liver transplantation remains high. The most common short-term biliary complication may be biliary leak. So, we examined 13 patients with biliary leak after liver transplantation, attempting to evaluate the role of endoscopic diagnosis and treatment of biliary leak and the incidence of bile duct stricture after healing of the leak. METHODS: Six cases of T-tube leak and seven cases of anastomosis leak complicating liver transplantation were enrolled in this prospective study. Six patients were treated by endoscopic plastic stent placement, two by nasobiliary catheter drainage, two by papillosphincterotomy, and three by nasobiliary catheter drainage combined with plastic stent placement. Some patients received growth hormone treatment. RESULTS: The bile leak resolution time was 10-35 days in 10 patients with complete documentation. The median time of leak resolution was 15.3 days. Four cases of anastomosis stricture, three cases of common hepatic duct and one case of multiple bile duct stenosis were detected by follow-up nasobiliary catheter cholangiography or endoscopic retrograde cholangiopancreatography. CONCLUSIONS: Endoscopic nasobiliary catheter or plastic stent placement is a safe and effective treatment for bile duct stricture occurring after bile leak resolution in most liver transplantation patients. Nasobiliary catheter combined with plastic stent placement may be the best choice for treating bile leak, because, theoretically, it may prevent the serious condition resulting from accidental nasobiliary catheter dislocation, and it may have prophylactic effects on upcoming bile duct stricture, although this should be further confirmed.展开更多
BACKGROUND: Bile leak remains a main complication in liver transplantation patients with poor biliary tract conditions, mainly caused by an insufficient blood supply or dysplasia of the biliary tract. Although Roux-en...BACKGROUND: Bile leak remains a main complication in liver transplantation patients with poor biliary tract conditions, mainly caused by an insufficient blood supply or dysplasia of the biliary tract. Although Roux-en-Y modus operandi can be adopted, the risk of other complications of the biliary tract such as infection increases. Using pedicled greater omentum flaps to wrap the anastomotic stoma, which increases the biliary tract blood supply, may reduce the incidence of bile leak. METHODS: Fourteen patients undergoing piggy-back liver transplantation and having poor biliary tract conditions were treated with pedicled greater omentum flaps to wrap the anastomotic stoma of the biliary tract. Their clinical data were analyzed retrospectively. RESULTS: Of the 14 patients, only one (7.1%) had a mild bile leak on the 8th day post-operation and fully recovered after symptomatic treatment. The other patients had no biliary complications. CONCLUSIONS: Using pedicled greater omentum flaps to wrap the anastomotic stoma of the biliary tract is an effective way to prevent bile leak in liver transplantation patients, especially those with poor biliary tract conditions. However, experience with this surgical technique still needs to be further explored.展开更多
AIM: To describe endoscopic treatment of bile leaks in these patients and to identify risk factors in these patients which can predict the development of bile leaks. METHODS: Retrospective case-control study examining...AIM: To describe endoscopic treatment of bile leaks in these patients and to identify risk factors in these patients which can predict the development of bile leaks. METHODS: Retrospective case-control study examining consecutive patients who underwent partial hepatectomy for polycystic liver disease (PLD) and developed a postoperative bile leak managed endoscopically over a ten year period. Each case was matched with two controls with PLD who did not develop a postoperative bile leak. RESULTS: Ten cases underwent partial hepatectomy with fenestration for symptoms including abdominal distention, pain and nausea. Endoscopic retrograde cholangiopancreatography (ERCP) showed anatomic abnormalities in 1 case. A biliary sphincterotomy was performed in 4 cases. A plastic biliary stent was placed with the proximal end at the site of the leak in 9 cases; in 1 case two stents were placed. The overall success rate of ERCP to manage the leak was 90%. There were no significant differences in age, gender, comorbidities, duration of symptoms, history of previous surgery or type of surgery performed between cases and controls. CONCLUSION: ERCP with stent placement is safe and effective for management of post-hepatectomy bile leak in patients with PLD.展开更多
BACKGROUND Laparoscopic cholecystectomy(LC)is one of the most frequently performed surgical procedures.Cystic stump leakage is an underestimated,potentially life threatening complication that occurs in 1%-6%of the pat...BACKGROUND Laparoscopic cholecystectomy(LC)is one of the most frequently performed surgical procedures.Cystic stump leakage is an underestimated,potentially life threatening complication that occurs in 1%-6%of the patients.With a secure cystic duct occlusion technique during LC,bile leakage becomes a preventable complication.AIM To investigate the effect of polydioxanone(PDS)loop closure of the cystic duct on bile leakage rate in LC patients.METHODS In this retrospective analysis of a prospective cohort,the effect of PDS loop closure of the cystic duct on bile leakage complication was compared to patients with conventional clip closure.Logistic regression analysis was used to develop a risk score to identify bile leakage risk.Leakage rate was assessed for categories of patients with increasing levels of bile leakage risk.RESULTS Of the 4359 patients who underwent LC,136(3%)underwent cystic duct closure by a PDS loop.Preoperatively,loop closure patients had significantly more complicated biliary disease compared to the clipped closure patients.In the loop closure cohort,zero(0%)bile leakage occurred compared to 59 of 4223(1.4%)clip closure patients.For patients at increased bile leakage risk(risk score≥1)rates were 1.6%and up to 13%(4/30)for clip closure patients with a risk score≥4.This risk increase paralleled a stepwise increase of actual bile leakage complication for clip closure patients,which was not observed for loop closure patients.CONCLUSION Cystic duct closure with a PDS loop during LC may reduce bile leakage in patients at increased risk for bile leakage.展开更多
BACKGROUND Bile leakage is a common and serious complication of open hepatectomy for the treatment of biliary tract cancer.AIM To evaluate the incidence,risk factors,and management of bile leakage after open hepatecto...BACKGROUND Bile leakage is a common and serious complication of open hepatectomy for the treatment of biliary tract cancer.AIM To evaluate the incidence,risk factors,and management of bile leakage after open hepatectomy in patients with biliary tract cancer.METHODS We retrospectively analyzed 120 patients who underwent open hepatectomy for biliary tract cancer from February 2018 to February 2023.Bile leak was defined as bile drainage from the surgical site or drain or the presence of a biloma on imaging.The incidence,severity,timing,location,and treatment of the bile leaks were recorded.The risk factors for bile leakage were analyzed using univariate and multivariate logistic regression analyses.RESULTS The incidence of bile leak was 16.7%(20/120),and most cases were grade A(75%,15/20)according to the International Study Group of Liver Surgery classification.The median time of onset was 5 d(range,1-14 d),and the median duration was 7 d(range,2-28 d).The most common location of bile leakage was the cut surface of the liver(70%,14/20),followed by the anastomosis site(25%,5/20)and the cystic duct stump(5%,1/20).Most bile leaks were treated conservatively with drainage,antibiotics,and nutritional support(85%,17/20),whereas some required endoscopic retrograde cholangiopancreatography with stenting(10%,2/20)or percutaneous transhepatic cholangiography with drainage(5%,1/20).Risk factors for bile leakage include male sex,hepatocellular carcinoma,major hepatectomy,blood loss,and blood transfusion.CONCLUSION Bile leakage is a frequent complication of open hepatectomy for biliary tract cancer.However,most cases are mild and can be conservatively managed.Male sex,hepatocellular carcinoma,major hepatectomy,blood loss,and blood transfusion were associated with an increased risk of bile leak.展开更多
文摘Orthotopic liver transplantation is the definitive treatment for end-stage liver disease and hepatocellular carcinomas.Biliary complications are the most common complications seen after transplantation,with an incidence of 10-25%.These complications are seen both in deceased donor liver transplant and living donor liver transplant.Endoscopic treatment of biliary complications with endoscopic retrograde cholangiopancreatography(commonly known as ERCP)has become a mainstay in the management post-transplantation.The success rate has reached 80%in an experienced endoscopist's hands.If unsuccessful with ERCP,percutaneous transhepatic cholangiography can be an alternative therapy.Early recognition and treatment has been shown to improve morbidity and mortality in post-liver transplant patients.The focus of this review will be a learned discussion on the types,diagnosis,and treatment of biliary complications post-orthotopic liver transplantation.
文摘The incidence of biliary injury after laparoscopic cholecystectomy(LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include:(1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations;(2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury;(3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy;(4) proper gallbladder retraction;(5) safe use of various energy devices;(6) understanding the critical view of safety, including its doublet view and documentation;(7) awareness of various error traps(e.g., fundus first technique);(8) use of various bailout strategies(e.g., subtotal cholecystectomy) in difficult gallbladder cases;(9) use of intraoperative imaging techniques(e.g., intraoperative cholangiogram) to ascertain correct anatomy; and(10) understanding the concept of time-out.Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
文摘AIM: To elucidate the impact of various donor recipient and transplant factors on the development of biliary complications after liver transplantation.METHODS: We retrospectively reviewed 200 patients of our newly established liver transplantation(LT) program, who received full size liver graft. Biliary reconstruction was performed by side-to-side(SS), end-to-end(EE) anastomosis or hepeaticojejunostomy(HJ). Biliary complications(BC), anastomotic stenosis, bile leak, papillary stenosis, biliary drain complication, ischemic type biliary lesion(ITBL) were evaluated by studying patient records, corresponding radiologic imaging and reports of interventional procedures [e.g., endoscopic retrograde cholangiopancreatography(ERCP)]. Laboratory results included alanine aminotransferase(ALT), gammaglutamyltransferase and direct/indirect bilirubin with focus on the first and fifth postoperative day, six weeks after LT. The routinely employed external bile drain was examined by a routine cholangiography on the fifth postoperative day and six weeks after transplantation as a standard procedure, but also whenever clinically indicated. If necessary, interventional(e.g., ERCP) or surgical therapy was performed. In case of biliary complication, patients were selected, assigned to different complication-groups and subsequently reviewed in detail. To evaluate the patients outcome, we focussed on appearance of postoperative/post-interventional cholangitis, need for rehospitalisation, retransplantation, ITBL or death caused by BC.RESULTS: A total of 200 patients [age: 56(19-72), alcoholic cirrhosis: n = 64(32%), hepatocellular carcinoma: n = 40(20%), acute liver failure: n = 23(11.5%), cryptogenic cirrhosis: n = 22(11%), hepatitis B virus /hepatitis C virus cirrhosis: n = 13(6.5%), primary sclerosing cholangitis: n = 13(6.5%), others: n = 25(12.5%) were included. The median follow-up was 27 mo until June 2015. The overall biliary complication rate was 37.5%(n = 75) with anastomotic strictures(AS): n = 38(19%), bile leak(BL): n = 12(6%
文摘BACKGROUND Laparoscopic cholecystectomy(LC)combined with laparoscopic common bile duct(CBD)exploration(LCBDE)is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm.However,for patients with small CBD(CBD diameter≤8 mm),endoscopic sphincterotomy remains the preferred treatment at present,but it also has some drawbacks associated with a series of complications,such as pancreatitis,hemorrhage,cholangitis,and duodenal perforation.To date,few studies have been reported that support the feasibility and safety of LCBDE for choledocholithiasis with small CBD.AIM To investigate the feasibility and safety of LCBDE for choledocholithiasis with small CBD.METHODS A total of 257 patients without acute cholangitis who underwent LC+LCBDE for cholecystolithiasis from January 2013 to December 2018 in one institution were reviewed.The clinical data were retrospectively collected and analyzed.According to whether the diameter of CBD was larger than 8 mm,257 patients were divided into large CBD group(n=146)and small CBD group(n=111).Propensity score matching(1:1)was performed to adjust for clinical differences.The demographics,intraoperative data,short-term outcomes,and long-term follow-up outcomes for the patients were recorded and compared.RESULTS In total,257 patients who underwent successful LC+LCBDE were enrolled in the study,146 had large CBD and 111 had small CBD.The median follow-up period was 39(14-86)mo.For small CBD patients,the median CBD diameter was 0.6 cm(0.2-2.0 cm),the mean operating time was 107.2±28.3 min,and the postoperative bile leak rate,rate of residual CBD stones(CBDS),CBDS recurrence rate,and CBD stenosis rate were 5.41%(6/111),3.60%(4/111),1.80%(2/111),and 0%(0/111),respectively;the mean postoperative hospital stay was 7.4±3.6 d.For large CBD patients,the median common bile duct diameter was 1.0 cm(0.3-3.0 cm),the mean operating time was 115.7±32.0 min,and the postoperative bile leak rate,rate of residual CBDS,CBDS recurrence rate,and CBD stenosis rate were 5.41%(9
文摘BACKGROUND: Iatrogenic bile duct injury continues to be an important clinical problem, resulting in serious morbidity, and occasional mortality, to patients. The ease of management, operative risk, and outcome of bile duct injuries vary considerably, and are highly dependent on the type of injury and its location. This article reviews the various classification systems of bile duct injury. DATA SOURCES: A Medline, PubMed database search was performed to identify relevant articles using the keywords 'bile duct injury', 'cholecystectomy', and 'classification'. Additional papers were identified by a manual search of the references from the key articles. RESULTS: Traditionally, biliary injuries have been classified using the Bismuth's classification. This classification, which originated from the era of open surgery, is intended to help the surgeons to choose the appropriate technique for the repair, and it has a good correlation with the final outcome after surgical repair. However, the Bismuth's classification does not encompass the whole spectrum of injuries that are possible. Bile duct injury during laparoscopic cholecystectomy tends to be more severe than those with open cholecystectomy. Strasberg's classification made Bismuth's classification much more comprehensive by including various other types of extrahepatic bile duct injuries. Our group, Bergman et al, Neuhaus et al, Csendes et al, and Stewart et al have also proposed other classification systems to complement the Bismuth's classification. CONCLUSIONS: None of the classification system is universally accepted as each has its own limitation. Hopefully, a universally accepted comprehensive classification system will be published in the near future.
文摘Liver transplantation is the optimal treatment for many patients with advanced liver disease, including decompensated cirrhosis, hepatocellular carcinoma and acute liver failure. Organ shortage is the maindeterminant of death on the waiting list and hence living donor liver transplantation(LDLT) assumes importance. Biliary complications are the most common post operative morbidity after LDLT and occur due to anatomical and technical reasons. They include biliary leaks, strictures and cast formation and occur in the recipient as well as the donor. The types of biliary complications after LDLT along with their etiology, presenting features, diagnosis and endoscopic and surgical management are discussed.
文摘Biliary complications(BC) currently represent a major source of morbidity after liver transplantation. Although refinements in surgical technique and medical therapy have had a positive influence on the reduction of postoperative morbidity, BC affect 5% to 25% of transplanted patients. Bile leak and anastomotic strictures represent the most common complications. Nowadays, a multidisciplinary approach is required to manage such complications in order to prevent liver failure and retransplantation.
文摘BACKGROUND: Orthotopic liver transplantation has been widely used in patients with end-stage liver disease within the last two decades. However, the prevalence of biliary complications after liver transplantation remains high. The most common short-term biliary complication may be biliary leak. So, we examined 13 patients with biliary leak after liver transplantation, attempting to evaluate the role of endoscopic diagnosis and treatment of biliary leak and the incidence of bile duct stricture after healing of the leak. METHODS: Six cases of T-tube leak and seven cases of anastomosis leak complicating liver transplantation were enrolled in this prospective study. Six patients were treated by endoscopic plastic stent placement, two by nasobiliary catheter drainage, two by papillosphincterotomy, and three by nasobiliary catheter drainage combined with plastic stent placement. Some patients received growth hormone treatment. RESULTS: The bile leak resolution time was 10-35 days in 10 patients with complete documentation. The median time of leak resolution was 15.3 days. Four cases of anastomosis stricture, three cases of common hepatic duct and one case of multiple bile duct stenosis were detected by follow-up nasobiliary catheter cholangiography or endoscopic retrograde cholangiopancreatography. CONCLUSIONS: Endoscopic nasobiliary catheter or plastic stent placement is a safe and effective treatment for bile duct stricture occurring after bile leak resolution in most liver transplantation patients. Nasobiliary catheter combined with plastic stent placement may be the best choice for treating bile leak, because, theoretically, it may prevent the serious condition resulting from accidental nasobiliary catheter dislocation, and it may have prophylactic effects on upcoming bile duct stricture, although this should be further confirmed.
文摘BACKGROUND: Bile leak remains a main complication in liver transplantation patients with poor biliary tract conditions, mainly caused by an insufficient blood supply or dysplasia of the biliary tract. Although Roux-en-Y modus operandi can be adopted, the risk of other complications of the biliary tract such as infection increases. Using pedicled greater omentum flaps to wrap the anastomotic stoma, which increases the biliary tract blood supply, may reduce the incidence of bile leak. METHODS: Fourteen patients undergoing piggy-back liver transplantation and having poor biliary tract conditions were treated with pedicled greater omentum flaps to wrap the anastomotic stoma of the biliary tract. Their clinical data were analyzed retrospectively. RESULTS: Of the 14 patients, only one (7.1%) had a mild bile leak on the 8th day post-operation and fully recovered after symptomatic treatment. The other patients had no biliary complications. CONCLUSIONS: Using pedicled greater omentum flaps to wrap the anastomotic stoma of the biliary tract is an effective way to prevent bile leak in liver transplantation patients, especially those with poor biliary tract conditions. However, experience with this surgical technique still needs to be further explored.
文摘AIM: To describe endoscopic treatment of bile leaks in these patients and to identify risk factors in these patients which can predict the development of bile leaks. METHODS: Retrospective case-control study examining consecutive patients who underwent partial hepatectomy for polycystic liver disease (PLD) and developed a postoperative bile leak managed endoscopically over a ten year period. Each case was matched with two controls with PLD who did not develop a postoperative bile leak. RESULTS: Ten cases underwent partial hepatectomy with fenestration for symptoms including abdominal distention, pain and nausea. Endoscopic retrograde cholangiopancreatography (ERCP) showed anatomic abnormalities in 1 case. A biliary sphincterotomy was performed in 4 cases. A plastic biliary stent was placed with the proximal end at the site of the leak in 9 cases; in 1 case two stents were placed. The overall success rate of ERCP to manage the leak was 90%. There were no significant differences in age, gender, comorbidities, duration of symptoms, history of previous surgery or type of surgery performed between cases and controls. CONCLUSION: ERCP with stent placement is safe and effective for management of post-hepatectomy bile leak in patients with PLD.
文摘BACKGROUND Laparoscopic cholecystectomy(LC)is one of the most frequently performed surgical procedures.Cystic stump leakage is an underestimated,potentially life threatening complication that occurs in 1%-6%of the patients.With a secure cystic duct occlusion technique during LC,bile leakage becomes a preventable complication.AIM To investigate the effect of polydioxanone(PDS)loop closure of the cystic duct on bile leakage rate in LC patients.METHODS In this retrospective analysis of a prospective cohort,the effect of PDS loop closure of the cystic duct on bile leakage complication was compared to patients with conventional clip closure.Logistic regression analysis was used to develop a risk score to identify bile leakage risk.Leakage rate was assessed for categories of patients with increasing levels of bile leakage risk.RESULTS Of the 4359 patients who underwent LC,136(3%)underwent cystic duct closure by a PDS loop.Preoperatively,loop closure patients had significantly more complicated biliary disease compared to the clipped closure patients.In the loop closure cohort,zero(0%)bile leakage occurred compared to 59 of 4223(1.4%)clip closure patients.For patients at increased bile leakage risk(risk score≥1)rates were 1.6%and up to 13%(4/30)for clip closure patients with a risk score≥4.This risk increase paralleled a stepwise increase of actual bile leakage complication for clip closure patients,which was not observed for loop closure patients.CONCLUSION Cystic duct closure with a PDS loop during LC may reduce bile leakage in patients at increased risk for bile leakage.
文摘BACKGROUND Bile leakage is a common and serious complication of open hepatectomy for the treatment of biliary tract cancer.AIM To evaluate the incidence,risk factors,and management of bile leakage after open hepatectomy in patients with biliary tract cancer.METHODS We retrospectively analyzed 120 patients who underwent open hepatectomy for biliary tract cancer from February 2018 to February 2023.Bile leak was defined as bile drainage from the surgical site or drain or the presence of a biloma on imaging.The incidence,severity,timing,location,and treatment of the bile leaks were recorded.The risk factors for bile leakage were analyzed using univariate and multivariate logistic regression analyses.RESULTS The incidence of bile leak was 16.7%(20/120),and most cases were grade A(75%,15/20)according to the International Study Group of Liver Surgery classification.The median time of onset was 5 d(range,1-14 d),and the median duration was 7 d(range,2-28 d).The most common location of bile leakage was the cut surface of the liver(70%,14/20),followed by the anastomosis site(25%,5/20)and the cystic duct stump(5%,1/20).Most bile leaks were treated conservatively with drainage,antibiotics,and nutritional support(85%,17/20),whereas some required endoscopic retrograde cholangiopancreatography with stenting(10%,2/20)or percutaneous transhepatic cholangiography with drainage(5%,1/20).Risk factors for bile leakage include male sex,hepatocellular carcinoma,major hepatectomy,blood loss,and blood transfusion.CONCLUSION Bile leakage is a frequent complication of open hepatectomy for biliary tract cancer.However,most cases are mild and can be conservatively managed.Male sex,hepatocellular carcinoma,major hepatectomy,blood loss,and blood transfusion were associated with an increased risk of bile leak.
