Preoperative Biliary Drainage Increases Infectious Complications after Hepatectomy for Proximal Bile Duct Tumor Obstruction

Background  The role of preoperative biliary drainage before liver resection in jaundiced patients remains controversial. The objective of this study is to compare the perioperative outcome of liver resection for carcinoma involving the proximal bile duct in jaundiced patients with and without preoperative biliary drainage. Methods  Seventy-four consecutive jaundiced patients underwent hepatectomy for carcinoma involving the proximal bile duct from January 1989 to June 2006 and their data were retrospectively analyzed. Fourteen patients underwent biliary drainage before portal vein embolization and were excluded from the study. Thirty patients underwent biliary drainage before hepatectomy and 30 underwent liver resection without preoperative biliary drainage. All patients underwent resection of the extrahepatic bile duct. Results  Overall mortality and operative morbidity were similar in the two groups (3% vs. 10%, p = 0.612 and 70% vs. 63%, p = 0.583, respectively). The incidence of noninfectious complications was similar in the two groups. There was no difference in hospital stay between the two groups. Patients with preoperative biliary drainage had a significantly higher rate of infectious complications (40% vs. 17%, p = 0.044). At multivariate analysis, preoperative biliary drainage was the only independent risk factor for infectious complication in the postoperative course (RR = 4.411, 95%CI = 1.216-16.002, p = 0.024). Even considering patients with preoperative biliary drainage in whom the bilirubin level went below 5 mg/dl, the risk of infectious complications was higher compared with patients without biliary drainage (47.6% vs. 16.6%, p = 0.017). Conclusions  Overall mortality and morbidity after liver resection are not improved by preoperative biliary drainage in jaundiced patients. Prehepatectomy biliary drainage increases the incidence of infectious complications.     

Catheter Tract Recurrence After Percutaneous Biliary Drainage for Hilar Cholangiocarcinoma

Background

Despite its wide use, catheter tract recurrence after percutaneous biliary drainage (PBD) is rarely reported. However, one recent large-scale study reported a catheter tract recurrence rate as high as 5.2 % in patients with perihilar or distal bile duct cancer. We report on our 20 years of experience with catheter tract seeding after PBD for hilar cholangiocarcinoma.

Methods

The medical records of 441 patients who underwent operation for hilar cholangiocarcinoma between 1991 and 2011 were retrospectively analyzed.

Results

Of the 441 patients with hilar cholangiocarcinoma, PBD was performed in 315 patients, and 232 others underwent resection of hilar cholangiocarcinoma with PBD. Catheter tract recurrence developed in 6 patients (2.6 %). The median drainage duration was 30 days, and 1 patient had multiple PBDs. The median time to catheter recurrence after surgery was 10.9 months. Three patients underwent curative resection of the abdominal wall followed by chemotherapy, 1 patient underwent chemotherapy only, and 2 patients received conservative treatment. Five patients in whom the catheter tract recurrence was their first recurrence died of systemic recurrence at median 3.9 months after detection of catheter tract seeding. T1 or 2 disease (66.7 vs. 31.3 %; p = 0.086) tended to have catheter tract seeding with marginal significance. The overall survival rate was lower in patients with catheter tract seeding than in those without (median 17.5 vs. 23.0 months; p = 0.089).

Conclusions

The PBD catheter tract recurrence rate for hilar cholangiocarcinoma was 2.6 %. However, patients with catheter tract recurrence had a poor prognosis despite complete surgical metastasectomy.     

Endoscopic and Percutaneous Preoperative Biliary Drainage in Patients with Suspected Hilar Cholangiocarcinoma

Introduction  

Controversy exists over the preferred technique of preoperative biliary drainage (PBD) in patients with hilar cholangiocarcinoma (HCCA) requiring major liver resection. The current study compared outcomes of endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD) in patients with resectable HCCA.     

Biliary Complications After Pediatric Liver Transplantation

ObjectivesAfter liver transplantation, biliary complications are more prevalent in pediatric patients, with reported rates varying between 15% and 30%.MethodsWe retrospectively analyzed biliary complications observed in 84 pediatric liver transplantation patients between July 2006 and September 2012. Biliary reconstruction was accomplished via a duct-to-duct anastomosis in 5 (83.3%) of the 6 patients receiving whole liver grafts and in 44 (56.4%) of the 78 patients who received a segmental live donor graft. For the remaining 34 patients with living donor and 1 patient with whole liver graft, Roux-en-Y hepaticojejunostomy was the preferred method.ResultsPost-transplantation biliary complications were encountered in 26 patients (30.1%). The biliary complication rate was 38% in 49 duct-to-duct anastomosis, whereas it was 20% in the hepaticojejunostomy group consisting of 35 recipients. Thirteen of the 18 biliary leaks were from duct-to-duct anastomoses and the remaining 5 were from the hepaticojejunostomies and 6 of the 8 biliary strictures were observed in recipients with duct-to-duct anastomosis. In 19 of the 26 patients, the biliary complications were successfully treated with interventional radiologic procedures and 1 was treated with stent placement during endoscopic retrograde cholangiopancreatography.ConclusionsPercutaneous interventional procedures are valuable, effective, and life-saving therapeutic alternatives for the treatment of bile leaks and strictures after pediatric liver transplantations.     

Perioperative Antibiotics Covering Bile Contamination Prevent Abdominal Infectious Complications After Pancreatoduodenectomy in Patients With Preoperative Biliary Drainage

Background

Although bile contamination caused by preoperative biliary drainage (PBD) is a risk factor for infectious complications after pancreatoduodenectomy, the appropriate perioperative antibiotic regimen remains unclear. We evaluated a perioperative antibiotic strategy targeting bile contamination associated with PBD procedures for preventing abdominal infectious complications after pancreatoduodenectomy.

Methods

Consecutive patients (n = 254) underwent pancreatoduodenectomy at a single center. Perioperative antibiotics were mainly cefazolin in non-PBD cases (n = 116) and cefozopran in internal-PBD cases (n = 87). They were based on preoperative bile cultures in 51 of the external-PBD cases. Intraoperative bile cultures were examined prospectively. Morbidity and abdominal infectious complication rates were evaluated.

Results

The incidence of positive intraoperative bile cultures was significantly higher in the internal-PBD (85 %) and external-PBD (90 %) cases than in the non-PBD cases (26 %) (p < 0.001). The 91 % susceptibility to cefazolin for non-PBD was significantly higher than the 61 % for internal-PBD or 45 % for external-PBD (p < 0.001). Overall morbidity rates (23, 23, and 25 %) and abdominal infectious complications (13, 17, and 14 %) did not differ among the non-PBD, internal-PBD, and external-PBD cases, respectively. Only susceptibility to perioperative antibiotics of biliary microorganisms classified as resistant was a significant independent risk factor for abdominal infectious complications (p = 0.003).

Conclusions

A perioperative antibiotic strategy particular to PBD procedures is valid for covering biliary microorganisms during pancreatoduodenectomy. Perioperative antibiotics covering bile contamination may prevent abdominal infectious complications after pancreatoduodenectomy in patients with and without PBD.     

肝移植术后胆道并发症患者内镜治疗的护理

对16例原位肝移植术后胆道并发症患者实施内镜逆行胰胆管造影(ERCP)检查及治疗.通过治疗前的心理护理,16例患者顺利接受ERCP治疗.10例肝外胆管狭窄患者3～4个月后吻合口狭窄治愈,4例胆瘘患者2周内胆瘘愈合,1例移植肝多发性硬化性胆管炎样狭窄患者,行乳头括约肌切开术后取出少量坏死胆管上皮样组织;另1例移植肝和受者胆管完全分离者再次行外科手术.提出治疗前做好心理护理及各项准备,治疗后严密观察病情,严格操作规程,预防感染,是保证治疗成功的关键.     

肝移植术后胆道并发症患者内镜治疗的护理

对16例原位肝移植术后胆道并发症患者实施内镜逆行胰胆管造影（ERCP）检查及治疗。通过治疗前的心理护理,16例患者顺利接受ERCP治疗。10例肝外胆管狭窄患者3~4个月后吻合口狭窄治愈,4例胆瘘患者2周内胆瘘愈合,1例移植肝多发性硬化性胆管炎样狭窄患者,行乳头括约肌切开术后取出少量坏死胆管上皮样组织;另1例移植肝和受者胆管完全分离者再次行外科手术。提出治疗前做好心理护理及各项准备,治疗后严密观察病情,严格操作规程,预防感染,是保证治疗成功的关键。     

Role of Preoperative Optimization of the Liver for Resection in Patients with Hilar Cholangiocarcinoma Type III

Background  

Long-term survival after complete resection of hilar cholangiocarcinoma remains disappointing. The aim of this retrospective study was to assess the impact of liver optimization on postoperative outcome of hilar cholangiocarcinoma type III.     

Impact of Preoperative Bevacizumab on Complications After Resection of Colorectal Liver Metastases: Case-Matched Control Study

Background

Chemotherapy may increase postoperative morbidity and mortality after liver surgery. Especially bevacizumab, a monoclonal antibody against vascular endothelial growth factor (VEGF), could have a detrimental effect. To assess the impact of neoadjuvant bevacizumab on clinical outcome after hepatectomy for colorectal liver metastases (CRLMs) this case-matched control study was initiated.

Methods

The multicentric data collection was performed in the Swiss HPB Center of the University Hospital Zurich (CH), the Department of Digestive Surgery and Transplantation Strasbourg (F), and the Division of Hepato-biliary-pancreatic surgery of “Josep Tureta” Hospital Girona (E). Consecutive patients operated onbetween July 2005 and December 2007 due to CRLMs who received neoadjuvant chemotherapy were assessed. Patients were divided in two groups: group A had neoadjuvant chemotherapy with bevacicumab, and group B had it without bevacizumab.

Results

No differences in overall morbidity (56 vs. 40% in the bevacizumab and control groups, respectively, p = 0.23) or mortality could be documented. Similarly, the incidence of severe postoperative complications was not statistically different between the bevacizumab and control groups (31 and 18%, respectively, p = 0.31). Wound complications were comparable (11% in the bevacizumab group compared and 9% in the control group, p = 1.00). However, bevacizumab was associated with a significantly decreased incidence of postoperative hepatic insufficiency (7 vs. 20%, p = 0.03).

Conclusions

No impact on the incidence or severity of complications by bevacizumab could be shown. Bevacizumab may even reduce the incidence of liver failure after liver surgery.     

Short- and Long-Term Outcomes of Liver Resection for Intrahepatic Cholangiocarcinoma Associated with the Metabolic Syndrome

World Journal of Surgery - While the metabolic syndrome (MS) is being recognized as an important risk factor for intrahepatic cholangiocarcinoma (ICC), the outcomes of liver resection in this...     

Biliary Complications After Orthotopic Liver Transplantation: The Hungarian Experience

Biliary complications (BC) significantly affect morbidity and mortality after orthotopic liver transplantation (OLT). The aim of this study was to analyze the incidence and types of biliary complications after OLT in Hungary. We retrospectively analyzed data of 471 adult liver transplant recipients between 1995 and 2011. Biliary complications occurred in 28% of patients. The most frequent BCs were bile duct stricture, stenosis (19%), biliary leakage (12%), and necrosis (BN: 6.4%). Biliary complications were associated with the incidence of acute rejection (51% vs 31%; P = .003), hepatic artery thrombosis (43% vs 11%; P < .001), and hepatic artery stenosis (26% vs 11%; P = .002). When cold ischemic time was longer than 12 hours, leakage (10% vs 3%; P = .043), ischemic type biliary lesion (20% vs 3.4%; P = .05), and BN (12% vs 3%; P = .067) were more often diagnosed post-OLT. Most of the biliary complications were treated by radiologic interventions (70%). Bile duct necrosis was associated with lower graft and patient survival. In conclusion, acute rejection, hepatic artery thrombosis/stenosis and cold ischemic time longer than 12 hours increase the incidence of BCs. Successful management of these risk factors can reduce the incidence of biliary complications and improve mortality.     

Preoperative Galactose Elimination Capacity Predicts Complications and Survival After Hepatic Resection

OBJECTIVE: To analyze a single center's 6-year experience with 258 consecutive patients undergoing major hepatic resection for primary or secondary malignancy of the liver, and to examine the predictive value of preoperative liver function assessment. SUMMARY BACKGROUND DATA: Despite the substantial improvements in diagnostic and surgical techniques that have made liver surgery a safer procedure, careful patient selection remains mandatory to achieve good results in patients with hepatic tumors. METHODS: In this prospective study, 258 patients undergoing hepatic resection were enrolled: 111 for metastases, 78 for hepatocellular carcinoma (HCC), 21 for cholangiocellular carcinoma, and 48 for other primary hepatic tumors. One hundred fifty-eight patients underwent segment-oriented liver resection, including hemihepatectomies, and 100 had subsegmental resections. Thirty-two clinical and biochemical parameters were analyzed, including liver function assessment by the galactose elimination capacity (GEC) test, a measure of hepatic functional reserve, to predict postoperative (60-day) rates of death and complications and long-term survival. All variables were determined within 5 days before surgery. Data were subjected to univariate and multivariate analysis for two patient subgroups (HCC and non-HCC). The cutoffs for GEC in both groups were predefined. Long-term survival (>60 days) was subjected to Kaplan-Meier analysis and the Cox proportional hazard model. RESULTS: In the entire group of 258 patients, a GEC less than 6 mg/min/kg was the only preoperative biochemical parameter that predicted postoperative complications and death by univariate and stepwise regression analysis. A GEC of more than 6 mg/min/kg was also significantly associated with longer survival. This predictive value could also be shown in the subgroup of 180 patients with tumors other than HCC. In the subgroup of 78 patients with HCC, a GEC less than 4 mg/min/kg predicted postoperative complications and death by univariate and stepwise regression analysis. Further, a GEC of more than 4 mg/min/kg was also associated with longer survival. CONCLUSIONS: This prospective study establishes the preoperative determination of the hepatic reserve by GEC as a strong independent and valuable predictor for short- and long-term outcome in patients with primary and secondary hepatic tumors undergoing resection.     

Preoperative Risk Factors Associated With Urinary Complications After Kidney Transplantation

Background

Only surgically irrelevant risk factors including sex, African-American ancestry, or exceptional U-stitch anastomosis have been identified to associate with urinary complications after kidney transplantation. The objective was to identify modifiable and nonmodifiable risk factors associated with urinary complications after kidney transplantation.

Biliary Complications After Liver Transplantation: Old Problems and New Challenges

Due to a vulnerable blood supply of the bile ducts, biliary complications are a major source of morbidity after liver transplantation (LT). Manifestation is either seen at the anastomotic region or at multiple locations of the donor biliary system, termed as nonanastomotic biliary strictures. Major risk factors include old donor age, marginal grafts and prolonged ischemia time. Moreover, partial LT or living donor liver transplantation (LDLT) and donation after cardiac death (DCD) bear a markedly higher risk of biliary complications. Especially accumulation of several risk factors is critical and should be avoided. Prophylaxis is still a major issue; however no gold standard is established so far, since many risk factors cannot be influenced directly. The diagnostic workup is mostly started with noninvasive imaging studies namely MRI and MRCP, but direct cholangiography still remains the gold standard. Especially nonanastomotic strictures require a multidisciplinary treatment approach. The primary management of anastomotic strictures is mainly interventional. However, surgical revision is finally indicated in a significant number of cases. Using adequate treatment algorithms, a very high success rate can be achieved in anastomotic complications, but in nonanastomotic strictures a relevant number of graft failures are still inevitable.     

Preoperative Infliximab is not Associated with an Increased Risk of Short-Term Postoperative Complications After Restorative Proctocolectomy and Ileal Pouch-Anal Anastomosis

Introduction  

Considerable controversy exists over whether the preoperative use of infliximab (IFX) for refractory ulcerative colitis (UC) increases the risk for surgical complications after restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA). The aim of this study was to assess the association between preoperative IFX use and short-term surgical complications in a single-surgeon cohort at a tertiary care academic center.