Precise planning based on 3D-printed dry-laboratory models can reduce perioperative complications of laparoscopic surgery for complex hepatobiliary diseases: a preoperative cohort study.

BACKGROUND & AIMS: Complications after laparoscopic liver resection (LLR) are important factors affecting the prognosis of patients, especially for complex hepatobiliary diseases. The present study aimed to evaluate the value of a three-dimensional (3D) printed dry-laboratory model in the precise planning of LLR for complex hepatobiliary diseases. METHODS: Patients with complex hepatobiliary diseases who underwent LLR were preoperatively enrolled, and divided into two groups according to whether using a 3D-printed dry-laboratory model (3D vs. control group). Clinical variables were assessed and complications were graded by the Clavien-Dindo classification. The Comprehensive Complication Index (CCI) scores were calculated and compared for each patient. Multivariable analysis was performed to determine the risk factors of postoperative complications. RESULTS: Sixty-two patients with complex hepatobiliary diseases underwent the precise planning of LLR. Among them, thirty-one patients acquired the guidance of a 3D-printed dry-laboratory model, and others were only guided by traditional enhanced CT or MRI. The results showed no significant differences between the two groups in baseline characters. However, compared to the control group, the 3D group had a lower incidence of intraoperative blood loss, as well as postoperative 30-day and major complications, especially bile leakage (all P < 0.05). The median score on the CCI was 20.9 (range 8.7-51.8) in the control group and 8.7 (range 8.7-43.4) in the 3D group (mean difference, -12.2, P = 0.004). Multivariable analysis showed the 3D model was an independent protective factor in decreasing postoperative complications. Subgroup analysis also showed that a 3D model could decrease postoperative complications, especially for bile leakage in patients with intrahepatic cholelithiasis. CONCLUSION: The 3D-printed models can help reduce postoperative complications. The 3D-printed models should be recommended for patients with complex hepatobiliary diseases undergoing precise planning LLR.

Applying LASSO logistic regression for the prediction of biliary complications after ex vivo liver resection and autotransplantation in patients with end-stage hepatic alveolar echinococcosis.

BACKGROUND: The purpose of this study was to explore the relevant risk factors associated with biliary complications (BCs) in patients with end-stage hepatic alveolar echinococcosis (HAE) following ex vivo liver resection and autotransplantation (ELRA) and to establish and visualize a nomogram model. METHODS: This study retrospectively analysed patients with end-stage HAE who received ELRA treatment at the First Affiliated Hospital of Xinjiang Medical University between August 1, 2010 and May 10, 2023. The least absolute shrinkage and selection operator (LASSO) regression model was applied to optimize the feature variables for predicting the incidence of BCs following ELRA. Multivariate logistic regression analysis was used to develop a prognostic model by incorporating the selected feature variables from the LASSO regression model. The predictive ability, discrimination, consistency with the actual risk, and clinical utility of the candidate prediction model were evaluated using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA). Internal validation was performed by the bootstrapping method. RESULTS: The candidate prediction nomogram included predictors such as age, hepatic bile duct dilation, portal hypertension, and regular resection based on hepatic segments. The model demonstrated good discrimination ability and a satisfactory calibration curve, with an area under the ROC curve (AUC) of 0.818 (95% CI 0.7417-0.8958). According to DCA, this prediction model can predict the risk of BCs occurrence within a probability threshold range of 9% to 85% to achieve clinical net benefit. CONCLUSIONS: A prognostic nomogram with good discriminative ability and high accuracy was developed and validated to predict BCs after ELRA in patients with end-stage HAE.

The Usefulness of High-Magnification Loupe for Reducing Biliary Complications After Liver Transplantation.

BACKGROUND: Despite advances in surgical techniques, biliary complications are still considered to be a technical "Achilles' heel" of liver transplantation (LT). The purpose of this study was to evaluate the effect of loupe magnification in reducing biliary complications after LT. MATERIALS AND METHODS: From April 2017 to February 2022, LT was performed on 307 patients in our center. Among them, except for 3 patients who underwent hepaticojejunostomy, 304 adult patients with LT were enrolled. They were divided into 3 groups according to the loupe magnification: 2.5 times (×2.5 group, n = 105), 3.5 times (×3.5 group, n = 95), and 5.0 times (×5.0 group, n = 105). RESULTS: Biliary complications occurred in 63 (20.7%) patients. Anastomosis site leakage occurred in 37 patients (12.2%), and stricture occurred in 52 patients (17.1%). Anastomosis site leakage occurred in 15 patients (14.3%) in the ×2.5 group, 15 patients (16.0%) in the ×3.5 group, and 7 patients (6.7%) in the ×5.0 group (P = .097). Biliary stricture occurred in 26 patients (24.8%) in the ×2.5 group, 15 patients (16.0%) in the ×3.5 group, and 11 patients (10.5%) in the ×5.0 group (P = .021). Total biliary complications occurred in 31 patients (29.5%) in the ×2.5 group, 19 patients in the ×3.5 group (20.2%), and 13 patients in the ×5.0 group (12.4%) (P = .009). CONCLUSION: The use of a high magnification loupe can reduce biliary complications in liver transplantation. Further large-scale analyses of clinical data or randomized controlled trials are required to support this study.

Efficacy and safety of endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy and biliary stenting in post-operative bile leaks.

BACKGROUND: We evaluated the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, balloon biliary tract scanning, and plastic stenting in diagnosing and treating bile duct leakage after laparoscopic cholecystectomy and hydatid cyst surgery in this study. METHODS: The study evaluated patients who underwent ERCP, sphincterotomy, and stenting for post-operative bile leakage. The patients were grouped under 4 groups (cystic duct stump, sac bed, hydatid cyst, and choledochal) according to the bile leakage de-tected in the ERCP procedure. The success of the procedure after the ERCP was evaluated by drain extraction time, whether early complications such as bleeding, pancreatitis, and perforation developed due to the ERCP procedure and the presence of obstructive pathology in ERCP. RESULTS: Clinical improvement was observed in 65/73 (89%) patients who underwent successful ERCP procedures, and their drains could be removed. The mean drain removal time was 32.69±23.32 days. After laparoscopic cholecystectomy, bile leakage was most frequently from the cystic duct stump. There was no difference between the groups in procedural success rates. Drain removal time was shorter in the patient group with leakage from the cystic duct compared to the other three groups (P<0.05). After the ERCP procedure, 5/73 (6.9%) patients had minor ERCP complications, which improved with medical treatment. No major ERCP complication was observed. In addition, 25/73 patients (34.2%) had obstructive pathology such as biliary stone and hydatid membrane. CONCLUSION: In patients with biliary leak due to laparoscopic cholecystectomy and hydatid cyst surgery, ERCP, sphincterotomy, balloon scanning, and plastic stenting are both highly effective and reliable options. They should be considered as the first-choice treat-ment approach in this patient group.

[Endoscopic intraluminal treatment of early biliary complications after orthotopic liver transplantation]. / Opyt endoskopicheskogo vnutriprosvetnogo lecheniya rannikh biliarnykh oslozhnenii posle ortotopicheskoi transplantatsii pecheni.

OBJECTIVE: To improve the outcomes after orthotopic liver transplantation (OLT) followed by early biliary complications via endoscopic bilioduodenal stenting. MATERIAL AND METHODS: The study enrolled 41 patients with early biliary complications within 90 days after OLT. All patients underwent endoscopic treatment between 2001 and 2021. There were 34 (82.9%) men and 7 (17.1%) women aged 48.5±12.5 years. Strictures and failure of biliary anastomosis occurred in 33 (80.5%) and 8 (19.5%) patients, respectively. RESULTS: After endoscopic treatment, serum bilirubin normalized in 3.3±0.86 days in patients with strictures (23.7 (16.4; 34.5) mmol/l, p<0.001). Diameter of lobar ducts as a criterion of biliary hypertension was normalized after 4 (2.5; 5.5) days (p<0.001). Bile leakage after stenting with a covered self-expanding stent regressed in all 7 patients after 3 (2; 5) days. In 1 patient, bile output through the drainage stopped in 8 days after bilioduodenal stenting with a plastic stent. CONCLUSION: Endoscopic bilioduodenal stenting is always effective and minimally invasive treatment after liver transplantation followed by early biliary complications (failure or stricture of anastomosis). This approach minimizes postoperative complications (9.8%) that do not require surgical intervention (Clavien-Dindo grade I).

Risk factors of postoperative bile leakage after liver resection: A systematic review and meta-analysis.

OBJECTIVE: Postoperative bile leakage (POBL) is one of the most common complications after liver resection. However, current studies on the risk factors for POBL and their impacts on surgical outcomes need to be more consistent. This study aims to conduct a meta-analysis to analyze the risk factors for POBL after hepatectomy. METHODS: We incorporated all eligible studies from Embase, PubMed, and the Web of Science database (until July 2022) into this study. RevMan and STATA software were used to analyze the extracted data. RESULTS: A total of 39 studies, including 43,824 patients, were included in this meta-analysis. We found that gender, partial hepatectomy, repeat of hepatectomy, extended hepatectomy, abdominal drain, diabetes, Child≥B, solitary tumor, and chemotherapy are the factors of grade B and C POBL. Some recognized risk factors were considered potential risk factors for grade B and C bile leakage because no subgroup analysis was performed, like HCC, cholangiocarcinoma, major resection, posterior sectionectomy, bi-segmentectomy, S4 involved, S8 involved, central hepatectomy, and bile duct resection/reconstruction. Meanwhile, cirrhosis, benign diseases, left hepatectomy, and Segment 1 resection were not significant for grade B and C bile leakage. The influence of lateral sectionectomy, anterior sectionectomy, S1 involved, S3 involved, high-risk procedure, laparoscope, and blood loss>1000 mL on POBL of ISGLS needs further research. Meanwhile, POBL significantly influenced overall survival (OS) after liver resection. CONCLUSIONS: We identified several risk factors for POBL after hepatectomy, which could prompt the clinician to decrease POBL rates and make more beneficial decisions for patients who underwent the hepatectomy.

Individualized Biliary Reconstruction Techniques in Liver Transplantation: Five Years' Experience of a Single Institution.

BACKGROUND: To summarize the experience of individualized biliary reconstruction techniques in deceased donor liver transplantation and explore potential risk factors for biliary stricture. METHODS: We retrospectively collected medical records of 489 patients undergoing deceased donor liver transplantation at our center between January 2016 and August 2020. According to anatomical and pathological conditions of donor and recipient biliary ducts, patients' biliary reconstruction methods were divided into six types. We summarized the experience of six different reconstruction methods and analyzed the biliary complications' rate and risk factors after liver transplantation. RESULTS: Among 489 cases of biliary reconstruction methods during liver transplantation, there were 206 cases of type I, 98 cases of type II, 96 cases of type III, 39 cases of type IV, 34 cases of type V, and 16 cases of type VI. Biliary tract anastomotic complications occurred in 41 cases (8.4%), including 35 cases with biliary stricture (7.2%), 9 cases with biliary leakage (1.8%), 19 cases with biliary stones (3.9%), 1 case with biliary bleeding (0.2%), and 2 cases with biliary infection (0.4%). One of 41 patients died of biliary tract bleeding and one died of biliary infection. Thirty-six patients significantly improved after treatment, and 3 patients received secondary transplantation. Compared with patients without biliary stricture, a higher warm ischemic time was observed in patients with non-anastomotic stricture and more leakage of bile in patients with an anastomotic stricture. CONCLUSION: The individualized biliary reconstruction methods are safe and feasible to decrease perioperative anastomotic biliary complications. Biliary leakage may contribute to anastomotic biliary stricture and cold ischemia time to non-anastomotic biliary stricture.

Biliary Complications in Living Liver Donors After Donor Hepatectomy: A Single-Center Experience.

OBJECTIVES: The most frequent postoperative morbidity following living donor liver transplant is biliary complications, which can happen for both anatomical and procedural reasons. MATERIALS AND METHODS: We conducted a retrospective analysis of 104 patients who were living liver donors undergoing hepatectomy from January 2011 to April 2022. We evaluated all perioperative finding such as age, sex, remnant liver volume, biliary anatomy, theduration of operation time and hospitalization, and blood loss. RESULTS: Clavien-Dindo classification grade III complications were observed in 24% of all donors, with rate of biliary complications of 7.6% (n = 8). All biliary complications were typified as biliary leakage, and an endoscopic retrograde cholangiopancreatography procedure was performed for 5 patients. We analyzed the clinical and surgical features and discovered that the duration of hospitalization was longer in the biliary leakage group than the group without leakage (15.7 ± 5.8 days vs. 30.8 ± 9.3 days, respectively; P < .08). There was no significant statistical relationship between age, the duration of operation time, intraoperative blood loss, and remnant liver volume versus biliary leakage (P = .074, P = .217, P = .219, and P = .363, respectively). CONCLUSIONS: Early detection and treatment of complications are ensured during the perioperative process by carefuldonor selection andaccurate identification of the patient atrisk for biliary complications.

Percutaneous Embolization of Biliary Leaks: Initial Experience with Extravascular Application of a PTFE-Covered Microplug.

PURPOSE: This paper describes the initial experience with a PTFE-covered microplug to perform extravascular embolizations in patients with iatrogenic biliary leaks. MATERIALS AND METHODS: A retrospective multicenter analysis has been conducted on seven patients. All were symptomatic for abdominal pain and had an abdominal drainage adjacent to the supposed site of leakage. The biliary output of the drainage was monitored daily. Biliary leak etiology was iatrogenic: four after laparoscopic cholecistectomy for gallstones, one after explorative laparotomy for pancreas head adenocarcinoma with concomitant cholecistectomy for gallstones, and two after long-standing internal-external right biliary drainage for cholangiocarcinoma. In four cases leakage sourced from cystic duct stump, in one from an aberrant bile duct and in two from bilio-cutaneous fistula. Technical success was considered leak resolution at the last cholangiography. Clinical success was defined improvement in the clinical conditions together with progressive resolution of the biliary output from the abdominal drainage until removal. RESULTS: Technical and clinical successes were 100%. A 5 mm microplug was adopted in five cases of post-cholecistectomy leaks. A 3 mm microplug and a 9 mm microplug were deployed in the two cases of peripheral leaks related to bilio-cutaneous fistulas. In three patients additional embolics (coils in two cases; spongel slurry in one case) were required. Minor complications occurred in three patients. CONCLUSION: This initial experience on seven patients with iatrogenic biliary leaks demonstrated that percutaneous transhepatic PTFE-covered microplug embolization is technically feasible and clinically effective to achieve leak resolution. Future researches with larger samples are needed to confirm these findings.

Risk Factors Related to Early Biliary Complications After Liver Transplantation: a Single-Center Analysis.

BACKGROUND: The aim of this study was to evaluate the risk factors of early biliary complications (EBC) after liver transplantation (LT) and seek effective treatments based on our single-center experience. METHODS: A total of 124 adult patients were divided into a non-EBC group and EBC group. EBC usually accounts for biliary leakage, biliary stricture, biliary stones, sphincter of Oddi dysfunction, and transient jaundice within 3 months after LT. Statistical analysis including logistic regression was performed to determine EBC risk factors. All procedures complied with the Helsinki Congress and the Declaration of Istanbul. RESULTS: Non-EBC (n = 95) and EBC (n = 29) were finally compared, which had no difference in their general characteristics. EBC occurred in 29 patients (26.92%): 1 biliary hemorrhage (3.45%), 7 biliary leakage (24.13%), and 16 biliary stricture (55.18%), and 5 others (17.24%). Of all EBC patients, endoscopic retrograde cholangiopancreatography (68.96%) was higher used to deal with complications than conservative treatment (10.35%), percutaneous transhepatic cholangial drainage (17.24%), and surgical treatment (3.45%). On univariate analyses, risk factors for EBC were bilirubin (P = .014), warm ischemia time (WIT) (P = .020), second WIT (P = .042), and operative time (OT) (P = .033). On multivariate analysis, independent risk factors for BC were WIT (P = .011) and OT (P = .049). CONCLUSIONS: The presence of WIT and OT were the independent risk factors for the development of EBC. In addition, we also confirmed that endoscopic retrograde cholangiopancreatography was beneficial and safe in the management of EBC after LT.

Incidence and risk factors for anastomotic bile leakage in hepatic resection with bilioenteric reconstruction - A international multicenter study.

BACKGROUND: Anastomotic leak (AL) after bilioenteric reconstruction (BR) is a feared complication after bile duct resection, especially in combination with liver resection. Literature on surgical outcome is sparse. This study aimed to determine the incidence and risk factors for AL after combined liver and bile duct resection with a focus on operative or endoscopic reinterventions. METHODS: Data from consecutive patients who underwent liver resection and BR between 2004 and 2018 in 11 academic institutions in Europe were collected from prospectively maintained databases. RESULTS: Within 921 patients, AL rate was 5.4% with a 30d mortality of 9.6%. Pringle maneuver (p<0.001),postoperative external biliary (p=0.007) and abdominal drainage (p<0.001) were risk factors for clinically relevant AL. Preoperative biliary drainage (p<0.001) was not associated with a higher rate of AL. AL was more frequent in stented patients (76.5%) compared to PTCD (17.6%) or PTCD+stent (5.9%,p=0.017). AL correlated with increased incidence of postoperative liver failure (p=0.036), cholangitis, hemorrhage and sepsis (all p<0.001). CONCLUSION: This multicenter data provides the largest series to date of LR with BR and could help in the management of these patients which are often challenging and hampering the patients' postoperative course negatively.

The use of the T-tube in biliary tract reconstruction during orthotopic liver transplantation: An umbrella review.

Biliary complications are one of the main concerns after liver transplantation, and to avoid these, the use of a T-tube has been advocated in biliary reconstruction. Most liver transplantation centres perform a biliary anastomosis without a T-tube to avoid the risk of complications and T-tube-related costs. Several meta-analyses have reached discordant conclusions regarding the benefits of using the T-tube. An umbrella review was performed to summarise quantitative measures about overall biliary complications, biliary leaks, biliary strictures and cholangitis associated with the T-tube use after liver transplantation. Published systematic reviews and meta-analyses related to the use of T-Tube in liver transplantation were searched and analysed. From the comprehensive literature search from PubMed, EMBASE and Cochrane Library databases on the 25th of October 2021, 104 records were retrieved. Seven meta-analyses and two systematic reviews were included in the final analysis. All the meta-analyses of RCT stated no differences in overall biliary complications and biliary leaks when using T-tube for a liver transplant (I2 ≥ 90% and I2 range 0-76%, respectively). The meta-analysis of the RCTs evaluating the risks of biliary strictures after liver transplantation showed that T-tube protects from the complication (I2 range 0-80%). Biliary anastomosis without a T-tube has equivalent overall biliary complications and bile leaks compared to the T-tube reconstruction. The incidence of biliary strictures is attenuated in patients with T-tubes, and most meta-analyses of RCTs have very low heterogeneity. Therefore, the present umbrella review suggests a selective T-tube use, particularly in small biliary ducts or transplants with marginal grafts at high risk of post-LT strictures.

Novel Personalized Score Predicts Risk for Postoperative Biliary Leak in Liver Surgery-a Retrospective Database Analysis.

BACKGROUND: The number of liver resections is constantly rising over the last decades. Despite the reduction of overall mortality and morbidity in liver surgery, biliary leakage is still a relevant postoperative complication that can lead to a fatal postoperative course. Aim of this analysis is the identification of specific risk factors for postoperative biliary complications after liver resections and the development of a predictive biliary leakage risk score. METHODS: A single-center, retrospective analysis of 844 liver resections performed in the Department of Visceral, Thoracic and Vascular Surgery, Technische Universität Dresden, between 1/2013 and 12/2019 is conducted to identify risk factors for postoperative biliary leakage and a risk score for biliary leakage after hepatectomy is established based on multivariate regression. The score has been validated by an independent validation cohort consisting of 142 patients. RESULTS: Overall morbidity is 43.1% with 36% surgical complications and an overall mortality of 4.3%. Biliary leakage occurred in 15.8% of patients. A predictive score for postoperative biliary leakage based on age, major resection, pretreatment with FOLFOX/cetuximab and operating time is created. Patients are stratified to low (< 15%) and high (> 15%) risk with a sensitivity of 67.4% and a specificity of 70.7% in development cohort and a specificity of 68.2% and sensitivity of 75.8% in validation cohort. CONCLUSIONS: The presented score is robust and has been validated in an independent patient cohort. Depending on the calculated risk, prevention or early treatment can be initiated to avoid bile leakage and to improve postoperative course.

Post-transplant biliary complications: advances in pathophysiology, diagnosis, and treatment.

Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease. Long-term survival is excellent, yet LT recipients are at risk of significant complications. Biliary complications are an important source of morbidity after LT, with an estimated incidence of 5%-32%. Post-LT biliary complications include strictures (anastomotic and non-anastomotic), bile leaks, stones, and sphincter of Oddi dysfunction. Prompt recognition and management is critical as these complications are associated with mortality rates up to 20% and retransplantation rates up to 13%. This review aims to summarise our current understanding of risk factors, natural history, diagnostic testing, and treatment options for post-transplant biliary complications.

Bile leak incidence, risk factors and associated outcomes in patients undergoing hepatectomy: a contemporary NSQIP propensity matched analysis.

BACKGROUND: Despite advances in surgical technique, bile leak remains a common complication following hepatectomy. We sought to identify incidence of, risk factors for, and outcomes associated with biliary leak. STUDY DESIGN: This is an ACS-NSQIP study. Distribution of bile leak stratified by surgical approach and hepatectomy type were identified. Univariate and multivariate factors associated with bile leak and outcomes were evaluated. RESULTS: Robotic hepatectomy was associated with less bile leak (5.4% vs. 11.4%; p < 0.001) compared to open. There were no significant differences in bile leak between robotic and laparoscopic hepatectomy (5.4% vs. 5.3%; p = 0.905, respectively). Operative factors risk factors for bile leak in patients undergoing robotic hepatectomy included right hepatectomy [OR 4.42 (95% CI 1.74-11.20); p = 0.002], conversion [OR 4.40 (95% CI 1.39-11.72); p = 0.010], pringle maneuver [OR 3.19 (95% CI 1.03-9.88); p = 0.044], and drain placement [OR 28.25 (95% CI 8.34-95.72); p < 0.001]. Bile leak was associated with increased reoperation (8.7% vs 1.7%, p < 0.001), 30-day readmission (26.6% vs 6.8%, p < 0.001), 30-day mortality (2% vs 0.9%, p < 0.001), and complications (67.2% vs 23.4%, p < 0.001) for patients undergoing MIS hepatectomy. CONCLUSION: While MIS confers less risk for bile leak than open hepatectomy, risk factors for bile leak in patients undergoing MIS hepatectomy were identified. Bile leaks were associated with multiple additional complications, and the robotic approach had an equal risk for bile leak than laparoscopic in this time period.

Percutaneous or Endoscopic Treatment of Peripheral Bile Duct Leaks: Initial Experience with an Innovative Approach of Microcatheter-Delivered Argon Plasma Coagulation.

PURPOSE: Biliary ductal injuries are challenging to treat, and often lead to severe morbidity and mortality. The first-line approach involves endoscopic retrograde cholangiopancreatography with sphincterotomy and, in case of refractory leakage, long-lasting percutaneous transhepatic biliary drainage, endoscopic or percutaneous injection of sclerosing agents and/or coiling can be used. We describe a treatment procedure using microcatheter-mediated percutaneous or endoscopic argon plasma coagulation (APC). MATERIALS AND METHODS: Three patients (7-year-old male, 14-year-old male, 81-year-old female) with refractory postsurgical and/or post-traumatic bile leaks underwent percutaneous (n = 2) or endoscopic (n = 1) APC through a detachable microcatheter. RESULTS: The procedure was technically feasible in all patients. Postoperative imaging showed complete occlusion of biliary leakage. The technique was uneventful intraoperatively with no adverse events occurring during recovery or follow-up. CONCLUSION: Our initial experience demonstrates that refractory bile duct leaks may be successfully treated with microcatheter-mediated APC endoscopically or percutaneously. Further research is needed to confirm the safety, efficacy, and clinical indications for this innovative technique.

Management of Biliary Complications in Liver Transplant Recipients.

Biliary complications are often referred to as the Achilles' heel of liver transplantation (LT). The most common of these complications include strictures, and leaks. Prompt diagnosis and management is key for preservation of the transplanted organ. Unfortunately, a number of factors can lead to delays in diagnosis and make adequate treatment a challenge. Innovations in advanced endoscopic techniques have increased non-surgical options for these complications and in many cases is the preferred approach.