Role of drain amylase levels assay and routinary postoperative day 3 abdominal CT scan in prevention of complications and management of surgical drains after pancreaticoduodenectomy.

To asses drains amylase (DA) cut-offs for the risk of clinically relevant postoperative pancreatic fistula (POPF) and define the optimal timing of drains removal based on daily DA assay and abdominal CT scan finding after pancreatoduodenectomy (PD). Different algorithms able to identify patients at higher risk of POPF and to assess the optimal time for drains removal after PD have been proposed. The most accurate DA cut-offs in the assessment of the risk of clinically relevant POPF were retrospectively identified. Data from a prospective trial for optimal timing of drains removal were analyzed. Then, to validate the cut-offs identified in the first phase, they were applied to the patients enrolled in the prospective trial. Patients with POD1 DA ≥ 666 U/L were at higher risk of clinically relevant POPF (p 0.0001). POD3 DA value ≥ 252 U/L predicted 88% of clinical relevant fistulas. POD3 DA level ≥ 207 U/L was able to predict 68% of biliary fistulas. Patients with abdominal collection ≥ 5 cm, showed a significantly higher rate (60% vs. 23%, p < 0.001) of biliary fistula. Timing of drains removal did not influence complications. Drains amylase levels predict clinically relevant POPF. Drains should be maintained up to POD3; in case of POD1 DA levels < 666 U/L and POD3 DA levels < 252 U/L drains could be removed. In case of POD3 DA levels, ≥ 207 the routine use of abdominal CT scan in the same day could be justified to detect collections ≥ 5 cm and maintain drains beyond the POD3.

Prevention of biliary fistula after partial hepatectomy by transcystic biliary drainage: randomized clinical trial.

BACKGROUND: Biliary fistula is one of the most common complications after hepatectomy. This study evaluated the effect of transcystic biliary drainage during hepatectomy on the occurrence of postoperative biliary fistula. METHODS: This multicentre RCT was carried out from 2009 to 2016 in nine centres. Patients were randomized to transcystic biliary drainage or no transcystic drainage (control). Patients underwent hepatectomy (more than 2 segments) of non-cirrhotic livers. The primary endpoint was the occurrence of biliary fistula after surgery. Secondary endpoints were morbidity, postoperative mortality, duration of hospital stay, reoperation, readmission to hospital, and complications caused by catheters. Intention-to-treat and per-protocol analyses were performed. RESULTS: A total of 310 patients were randomized. In intention-to-treat analysis, there were 158 patients in the transcystic group and 149 in the control group. Seven patients were removed from the per-protocol analysis owing to protocol deviations. The biliary fistula rate was 5·9 per cent in intention-to-treat and 6·0 per cent in per-protocol analyses. The rate was similar in the transcystic and control groups (5·7 versus 6·0 per cent; P = 1·000). There were no differences in terms of morbidity (49·4 versus 46·3 per cent; P = 0·731), mortality (2·5 versus 4·7 per cent; P = 0·367) and reoperations (4·4 versus 10·1 per cent; P = 1·000). Median duration of hospital stay was longer in the transcystic group (11 versus 10 days; P = 0·042). The biliary fistula risk was associated with the width and length of the hepatic cut surface. CONCLUSION: This randomized trial did not demonstrate superiority of transcystic drainage during hepatectomy in preventing biliary fistula. The use of transcystic drainage during hepatectomy to prevent postoperative biliary fistula is not recommended. Registration number: NCT01469442 ( http://www.clinicaltrials.gov).

ANTECEDENTES: La fístula biliar es una de las complicaciones más comunes después de la hepatectomía. Este estudio evalúa el efecto del drenaje biliar transcístico durante la hepatectomía en la aparición de una fístula biliar postoperatoria. MÉTODOS: Este ensayo prospectivo aleatorizado y multicéntrico (Clinical Trial NCT01469442) con dos grupos de estudio (grupo transcístico versus grupo control) se llevó a cabo de 2009 a 2016 en 9 centros. Los pacientes fueron sometidos a una hepatectomía (≥ 2 segmentos) en hígados no cirróticos. El resultado principal fue la aparición de una fístula biliar después de la cirugía. Los resultados secundarios fueron la morbilidad, la mortalidad postoperatoria, la duración de la estancia hospitalaria, la reintervención, la necesidad de reingreso y las complicaciones causadas por los catéteres. Se realizaron análisis por intención de tratamiento y por protocolo. RESULTADOS: Un total de 310 pacientes fueron randomizados. Por intención de tratamiento, 158 pacientes fueron aleatorizados al grupo transcístico y 149 al grupo control. Siete pacientes fueron excluidos del análisis por protocolo por desviaciones del protocolo. La tasa de fístula biliar fue del 5,9% en el análisis por intención de tratamiento y del 6,0% en el análisis por protocolo. Esta tasa fue similar para el grupo transcístico y para el grupo control: 5,7% versus 6,0% (P = 1). No hubo diferencias en términos de morbilidad (49,4% versus 46,9%, P = 0,731), mortalidad (2,5% versus 4,7%, P = 0,367) y reintervenciones (4,4% versus 10,1%, P = 1). La mediana de la duración de la estancia hospitalaria fue mayor para el grupo transcístico (11 versus 10 días, P = 0,042). El riesgo de fístula biliar se correlacionó con el grosor y la longitud de la transección hepática. CONCLUSIÓN: Este ensayo aleatorizado no demuestra la superioridad del drenaje transcístico durante la hepatectomía para prevenir la fístula biliar. No se recomienda el uso de drenaje transcístico durante la hepatectomía para prevenir la fístula biliar postoperatoria.

Eficacia del sellante de fibrina-colágeno para reducir la incidencia de fístulas biliares tras la exploración laparoscópica de la vía biliar / Efficacy of fibrin-sealants in reducing biliary leakage following laparoscopic common bile duct exploration

INTRODUCCIÓN: A pesar de la experiencia existente con la exploración laparoscópica de la vía biliar principal (ELVBP) en el tratamiento de la coledocolitiasis y de su eficacia bien demostrada, hay un riesgo de aparición de fístulas biliares de entre un 5 y un 15% tras el cierre de la coledocotomía. Evaluamos la utilidad de los sellantes de fibrina-colágeno para reducir la incidencia de fístulas biliares tras la coledocorrafia laparoscópica. MÉTODOS: Presentamos un análisis retrospectivo de 96 pacientes diagnosticados de coledocolitiasis sometidos a ELVBP desde marzo de 2009 a marzo de 2017. El cierre de la vía biliar se completó mediante coledocorrafia tras colocación de stent plástico transpapilar (CS) o realizando una sutura primaria (CP). La población de estudio fue dividida en dos grupos: pacientes con coledocorrafia cubierta con una lámina de colágeno-fibrina (GL) y pacientes con coledocorrafia sin cubrir (GSL). Se presenta el análisis de incidencia de aparición de fístulas biliares postoperatorias. RESULTADOS: Treinta y nueve pacientes (41%) fueron incluidos en el grupo GL, mientras que el grupo GSL fue formado por los 57 pacientes restantes (59%). Se demostró la homogeneidad de los grupos. La incidencia de fístulas biliares fue del 7,7% (3 pacientes) en el primer grupo y del 14% (8 pacientes) en el segundo (p = 0,338). La lámina de fibrina-colágeno redujo la incidencia de fístulas biliares de forma significativa en el subgrupo de los pacientes con CP (4,5% vs 33%, p = 0,020), siendo un factor protector con una odds ratio de 10,5. CONCLUSIÓN: La lámina de fibrina-colágeno aplicada sobre la coledocorrafia tras un cierre primario de la vía biliar puede tener un papel importante en la reducción significativa de la incidencia de fístulas biliares postoperatorias

INTRODUCTION: In spite of the acquired experience with laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis management, there is still a risk of biliary leakage of 5% to 15% following choledochotomy closure. We evaluate the usefulness of fibrin-collagen sealants to reduce the incidence of biliary fistula after laparoscopic choledochorrhaphy. METHODS: We report a retrospective analysis of 96 patients undergoing LCBDE from March 2009 to March 2017, whose closure of the bile duct was completed by antegrade stenting and choledochorraphy or by performing a primary suture. The study population was divided into two groups according to whether they received a collagen-fibrin sealant covering the choledochorrhaphy or not, analyzing the incidence of postoperative biliary fistula in each group. RESULTS: Thirty-nine patients (41%) received a fibrin-collagen sponge while the bile duct closure was not covered in the remaining 57 patients (59%). The incidence of biliary fistula was 7.7% (3 patients) in the first group and 14% (8 patients) in the second group (P = .338). In patients who underwent primary choledochorraphy, the fibrin-collagen sealant reduced the incidence of biliary leakage significantly (4.5% vs. 33%, P = .020), which was a protective factor with an odds ratio of 10.5. CONCLUSION: Fibrin-collagen sealants may decrease the incidence of biliary fistula in patients who have undergone primary bile duct closure following LCBDE

The Role of Prophylactic Endoscopic Sphincterotomy for Prevention of Postoperative Bile Leak in Hydatid Liver Disease: A Randomized Controlled Study.

BACKGROUND: Bile leak is the main cause of morbidity and mortality after surgery for hydatid liver cysts. Aim was to assess the role of prophylactic endoscopic sphincterotomy (ES) in reducing postoperative bile leak in patients undergoing partial cystectomy. METHODS: Fifty-four patients with hepatic hydatid cyst met inclusion criteria, 27 were excluded or declined to participate. Twenty-six women and 28 men (mean age 44.6 ± 10.1, range: 22-61 years) were randomly assigned to either group I with ES (n = 27) or group II without ES (n = 27). RESULTS: Demographics and clinical, laboratory, and radiological characteristics of cysts were not statistically different between two groups. Group I had a significant decrease in bile leak rate compared with group II (11.1% versus 40.7%, P = .013), with significantly shorter duration of hospital stay (P < .0001). Biliary fistula in group I had significantly lower daily output (100 mL/day versus 350 mL/day) with gradual reduction till stoppage of leak in 3-4 days without intervention. Biliary fistula in group II had a significantly higher need for biliary intervention through postoperative endoscopic retrograde cholangiopancreatography with ES compared with biliary fistula in group I (FEP = .002), with significantly longer mean time of fistula closure (P = .011) and longer time to drain removal (P < .0001). Nonbiliary complications were comparable between two groups. CONCLUSION: Prophylactic ES provides significant reduction in postoperative bile leak rate with shorter hospital stay after partial cystectomy of hydatid cyst. Biliary fistula in patients with ES has significantly lower daily output with shorter time of drain removal and shorter time to closure than patients without ES.

Occlusion of a Long-Term Transpleural Biliary Drainage Tract Using a Gelatin Pledget (Hep-Plug™).

This case describes a technique used to close a long-term 14F transpleural biliary drainage catheter tract to prevent biliopleural fistula and further complications. We deployed a compressed gelatin foam pledget provided in a pre-loaded delivery device (Hep-Plug™) along the intrahepatic tissue tract for sealing it against the pleural cavity. The device used is easy to handle and gives the Interventional Radiologist the possibility to safely manage and prevent complications after percutaneous transhepatic interventions.

Biliary fistula after liver resection: central role of intraoperative perihepatic drain.

BACKGROUNDː Despite notable advances in surgical skills and technology, incidence of biliary fistula after hepatic resection remains an issue. Aim of this study was to assess the role of intraoperative perihepatic drain in diagnosis and treatment of this complication. METHODSː The study included 641 patients who underwent hepatic resection without hepaticojejunostomy between Jan-2003 and Jan-2016. Data were obtained from our single-institution perspective database. RESULTSː Biliary fistula occurred in 3.4% (22/641). Major hepatic resection (P<0.001), S4-involving resection (P=0.006), cholangiocarcinoma (P<0.001) and intraoperative blood losses >375 mL (P<0.001) were associated with biliary fistula. At multivariate analysis, among patients with effective intraoperative perihepatic drain ("D" group) (16/22) onset of biliary fistula (mean, 5.1 vs. 31.5 days, P=0.12) and healing time (mean, 26.5 vs. 82.3 days, P=0.033) were more favorable compared with biloma group (B). Moreover, conservative treatment was more effective in D group (75% of cases). B group developed increased morbidity in terms of jaundice (83.3% vs. 18.7%, P=0.005), abscess (66.7% vs. 6.2%, P=0.003) and a trend of prolonged hospital stay (mean, 25.7 vs. 19.2 days, P=0.51) and mortality (16.7% vs. 6.2%, P=0.449). Difference in biliary fistula severity rate according to ISGLS classification between the two groups was statistically significant (P=0.003). CONCLUSIONSː This study confirms that the wider is the resection the higher the risk for biliary fistula. A correct drainage of bile leakage is the crucial requisite for early healing, providing a milder postoperative course. In our experience, intraoperative perihepatic drain positioning plays a key-role, as well as postoperative patency monitoring.

[Hemihepatectomy]. / Hemihepatektomie.

Hemihepatectomy continues to be a standard procedure for the resection of primary or secondary liver tumours in hepatobiliary surgery. In this tutorial, a case study illustrates the indication for liver resection as well as surgical steps and different techniques. Indications for right or left hemihepatectomy include liver tumours that cause a diffuse or extended infiltration of one half of the liver or tumours extending to the central confluence of liver veins or the liver hilum. Usually, a resection limit is only required in the case of extended hemihepatectomies, where a two-stage resection is needed. In addition to exploration and intraoperative ultrasound, this tutorial presents different entry sites, liver mobilisation, hilum preparation and common techniques of parenchymal dissection. Finally, a number of haemostasis, closure and biliary monitoring techniques are shown. The video tutorial demonstrates all fundamental steps of hemihepatectomy from indication to closure, with a special focus on different approaches.

Omental flaps reduces complications after pancreaticoduodenectomy.

BACKGROUND: Major complications after pancreaticoduodenectomy are usually caused by a leaking pancreaticojejunal anastomosis. Omental flaps around various anastomoses were used to prevent the formation of fistula. METHODS: We reviewed 147 patients who had undergone pancreaticoduodenectomy between March 2006 and March 2012. The patients were divided into 2 groups according to the application of omental flaps around various anastomoses: group A (101 patients) who underwent omental wrapping procedure; group B (46 patients) who did not undergo the omental wrapping procedure. Perioperative data of the two groups were reviewed to assess the effectiveness of omental flap procedure in the prevention of pancreatic fistula and other complications. RESULTS: No differences were observed in the clinical characteristics between the 2 groups. The incidences of pancreatic fistula (4.0% vs 17.4%), post-pancreatectomy hemorrhage (0 vs 6.5%), biliary fistula (1.0% vs 13.0%), and delayed gastric emptying (4.0% vs 17.4%) were significantly less frequent in group A. The overall morbidity (18.8% vs 47.8%) and hospital stay (8.3 vs 9.6 days) were also significantly lower in group A than in group B. CONCLUSIONS: Omental flaps around various anastomoses after pancreaticoduodenectomy can reduce the incidences of pancreatic fistula, biliary fistula, post-pancreatectomy hemorrhage and delayed gastric emptying. This procedure is simple and effective to reduce the overall morbidity after pancreaticoduodenectomy.

[Biliary leaks after liver resection. Prevention and treatment]. / Gallenleckage nach Leberresektion. Vermeidung und Behandlung.

The surgical treatment of primary and secondary liver pathologies is nowadays standard practice. Since the first major resections performed by Langenbruch in 1888 there have been significant developments in the surgical technique. In addition to the surgical technique, the diagnostics and patient selection, perioperative care and anesthetic management as well as knowledge of liver anatomy and physiology have also shown significant developments. The proportion of complex operations, even within the framework of multimodal concepts has also increased. Despite this increasing complexity, the morbidity (< 45 %) and mortality (< 5 %) of liver surgery could be clearly reduced; however, the incidence of postoperative biliary leaks in large published series currently lies between 0 % and 30 % and has only shown a minimal reduction in recent years. The management of bile leakage requires an interdisciplinary management involving endoscopic and radiological, interventional or operative therapy. Most leakages (69-94 %) persist under conservative treatment (drainage and if necessary antibiotic therapy). For high volume fistulas and persistent biliary leakage endoscopic retrograde cholangiography (ERC) with stent placement represents the therapy of choice. Infections with biliary peritonitis and failure of interventional strategies often require revision surgery, possibly consisting of suturing if a leakage is identifiable, replacement of drainages or application of a bile duct drainage (e.g. T-drain or transhepatic external biliary drainage).

Pancreaticogastrostomy is superior to pancreaticojejunostomy for prevention of pancreatic fistula after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials.

OBJECTIVE: To review prospective randomized controlled trials to determine whether pancreaticogastrostomy (PG) or pancreaticojejunostomy (PJ) is associated with lower risks of mortality and pancreatic fistula after pancreaticoduodenectomy (PD). BACKGROUND: Previous studies comparing reconstruction by PG and PJ reported conflicting results regarding the relative risks of mortality and pancreatic fistula after these procedures. METHODS: MEDLINE, the Cochrane Trials Register, and EMBASE were searched for prospective randomized controlled trials comparing PG and PJ after PD, published up to November 2013. Meta-analysis was performed using Review Manager 5.0. RESULTS: Seven trials were selected, including 562 patients who underwent PG and 559 who underwent PJ. The pancreatic fistula rate was significantly lower in the PG group than in the PJ group (63/562, 11.2% vs 84/559, 18.7%; odds ratio = 0.53; 95% confidence interval, 0.38-0.75; P = 0.0003). The overall mortality rate was 3.7% (18/489) in the PG group and 3.9% (19/487) in the PJ group (P = 0.68). The biliary fistula rate was significantly lower in the PG group than in the PJ group (8/400, 2.0% vs 19/392, 4.8%; odds ratio = 0.42; 95% confidence interval, 0.18-0.93; P = 0.03). CONCLUSIONS: In PD, reconstruction by PG is associated with lower postoperative pancreatic and biliary fistula rates.

[Liver transection: modern procedure: Technique, results and costs]. / Lebertranssektion: moderne Verfahren : Technik, Ergebnisse und Kosten.

Liver resection has developed into the current standard procedure due to modern resection techniques, profound knowledge of the liver anatomy and optimized surgical and anesthesiological strategies to allow extended resections with both low morbidity and mortality. Initially major blood loss was the biggest concern with liver resection and a Pringle's manoeuvre was necessary. Nowadays, biliary leakage is the major problem after liver surgery. Besides the classical conventional clamp crushing technique for parenchymal transection, various devices including ultrasound, microwaves and staplers have been introduced. Minimally invasive techniques have become increasingly important for liver resection but are still applied in selected patients only. The selection of the resection technique and device mainly depends on the extent of the resection and also on the liver parenchyma, the liver disease, costs, personal experiences and preferences. This article presents a selection of techniques used in modern parenchymal transection during liver resection with special focus on transection time, blood loss, bile leakage and costs.

Rubber transcystic drainage reduces the post-removal biliary complications in liver transplantation: a matched case-control study.

PURPOSE: Bile duct (BD) complications continue to be the "Achilles' heel" of liver transplantation, and the utilization of bile duct drainage is still on debate. We describe the results of a less invasive rubber trancystic biliary drainage (TBD) compared to a standard silicone T-tube (TT). METHODS: The transplanted patients (n = 248), over a period of 5 years with a TBD (n = 20), were matched 1:2 with control patients with a TT (n = 40). Primary end points were the overall incidence of BD complications and graft and patient survival. Secondary end points included the complications after the drainage removal. RESULTS: Although the bile duct leakage rates were not significantly different between both groups, the TT group had a significantly higher rate of overall 1-year BD stenosis (40 versus 10 %) (p = 0.036). Three-year patient/graft survival rates were 83.2/80.1 and 84.4/84.4 % for the TT and TBD groups, respectively. The postoperative BD complications, after drainage removal (peritonitis and stenosis), were significantly reduced (p = 0.011) with the use of a TBD. CONCLUSION: The use of rubber TBD in liver transplant recipients does not increase the number of BD complications compared to the T-tube. Furthermore, less BD anastomotic stenosis and post-removal complications were observed in the TBD group compared to the TT group.

[Hepaticojejunostomy after pancreatic head resection - technical aspects for reconstruction of small and fragile bile ducts with T-tube drainage]. / Die Technik der Hepatikojejunostomie mit T-Drainage bei der Rekonstruktion schmalkalibriger Gallengänge nach Pankreaskopfresektion.

BACKGROUND: After pancreatic head resection the reconstruction of small and fragile bile ducts is technically demanding, resulting in more postoperative bile leaks. One option for the reconstruction is the placement of a T-tube drainage at the site of the anastomosis. MATERIAL AND METHODS: Standard reconstruction after pancreatic head resection was an end-to-side hepaticojejunostomy with PDS 5.0, 15-25 cm distally from the pancreaticojejunostomy. For patients with a small bile duct diameter (≤ 5 mm) or a fragile bile duct wall the reconstruction was performed with PDS 6.0 and a T-tube drainage at the side of the anastomosis. RESULTS: The reconstruction with a T-tube drainage at the site of the anastomosis is technically easy to perform and offers the opportunity for immediate visualisation of the anastomosis in the postoperative period by application of water soluble contrast medium. If a bile leak occurs, biliary deviation through the T-tube drainage can enable a conservative management without revisional laparotomy in selected patients. Whether or not a conservative management of postoperative bile leaks will lead to more bile duct strictures is a subject for further investigations. CONCLUSION: A T-tube drainage at the site of the anastomosis can probably not prevent postoperative bile leaks from a difficult hepaticojejunostomy, but in selected patients it offers the opportunity for a conservative management resulting in less re-operations. Therefore we recommend the augmentation of a difficult hepaticojejunostomy with a T-tube drainage.

Does fibrin glue prevent biliary and pancreatic fistula after surgical resection?

BACKGROUND/AIMS: Efficacy of fibrin glue to prevent biliary or pancreas fistula at the resected edge of the liver or pancreas is controversial. We examined surgical results of fibrin glue use in patients who underwent hepatectomy or pancreatectomy to assess the efficacy of its use. METHODOLOGY: Subjects were divided into two groups; the fibrin glue group in hepatectomy (n=228) and in pancreatectomy (n=113), and the non-fibrin glue group in hepatectomy (n=94) and in pancreatectomy (n=24). In case of hepatectomy, the fibrin glue was sprayed on the cut-surface or anastomotic site of hepatico-jejunostomy. In case of pancreatectomy, the fibrin glue was sprayed on the anastomotic site of pancreato-jejunostomy or closed pancreatic stump. RESULTS: In the hepatectomy group, uncontrolled ascites were more frequent in the fibrin glue group (p<0.05). The use of fibrin glue for both groups has been less frequent in recent years. Prevalence of biliary fistula was not significantly different between groups. Hospital stay in the fibrin glue group was significantly longer than that in the non-fibrin glue group, and was not significantly different between hepatectomy or pancreatectomy groups. There was no significant difference of any complications including pancreatic fistula between groups. Prevalence of pancreatic fistula was not significantly different between the fibrin glue group and the non-fibrin glue group. CONCLUSIONS: Use of fibrin glue did not prevent biliary or pancreatic fistula in patients who underwent hepatectomy and pancreatectomy with or without enteric anastomosis.