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Bile Leak (bile + leak)
Selected AbstractsENDOSCOPIC OCCLUSION OF CYSTIC DUCT USING N -BUTYL CYANOACRYLATE FOR POSTOPERATIVE BILE LEAKAGEDIGESTIVE ENDOSCOPY, Issue 4 2010Eric K. Ganguly Bile leak after cholecystectomy is well described, with the cystic duct remnant the site of the leak in the majority of cases. Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement has a high success rate in such cases. When ERCP fails, options include surgery, and percutaneous and endoscopic transcatheter occlusion of the site of bile leak. Here, we describe a case of endoscopic transcatheter occlusion of a persistent cystic duct bile leak after cholecystectomy using N -butyl cyanoacrylate glue. A 51-year-old man had persistent pain and bilious drainage following a laparoscopic cholecystectomy. The bile leak persisted after endoscopic placement of a biliary stent for a confirmed cystic duct leak. A repeat ERCP was carried out and the cystic duct was occluded with a combination of angiographic coils and N -butyl cyanoacrylate glue. The patient's pain and bilious drainage resolved. A follow-up cholangiogram confirmed complete resolution of the cystic duct leak and a patent common bile duct. [source] Utility of the Gyrus open forceps in hepatic parenchymal transectionHPB, Issue 3 2009Matthew R. Porembka Abstract Objective:, This study aimed to evaluate if the Gyrus open forceps is a safe and efficient tool for hepatic parenchymal transection. Background:, Blood loss during hepatic transection remains a significant risk factor for morbidity and mortality associated with liver surgery. Various electrosurgical devices have been engineered to reduce blood loss. The Gyrus open forceps is a bipolar cautery device which has recently been introduced into hepatic surgery. Methods:, We conducted a single-institution, retrospective review of all liver resections performed from November 2005 through November 2007. Patients undergoing resection of at least two liver segments where the Gyrus was the primary method of transection were included. Patient charts were reviewed; clinicopathological data were collected. Results:, Of the 215 open liver resections performed during the study period, 47 patients met the inclusion criteria. Mean patient age was 61 years; 34% were female. The majority required resection for malignant disease (94%); frequent indications included colorectal metastasis (66%), hepatocellular carcinoma (6%) and cholangiocarcinoma (4%). Right hemihepatectomy (49%), left hemihepatectomy (13%) and right trisectionectomy (13%) were the most frequently performed procedures. A total of 26 patients (55%) underwent a major ancillary procedure concurrently. There were no operative mortalities. Median operative time was 220 min (range 97,398 min). Inflow occlusion was required in nine patients (19%) for a median time of 12 min (range 3,30 min). Median total estimated blood loss was 400 ml (range 10,2000 ml) and 10 patients (21%) required perioperative transfusion. All patients had macroscopically negative margins. Median length of stay was 8 days. Two patients (4%) had clinically significant bile leak. The 30-day postoperative mortality was zero. Conclusions:, Use of the Gyrus open forceps appears to be a safe and efficient manner of hepatic parenchymal transection which allows rapid transection with acceptable blood loss, a low rate of perioperative transfusion, and minimal postoperative bile leak. [source] Handling of biliary complications following laparoscopic cholecystectomy in the setting of Tripoli Central HospitalHPB, Issue 3 2002A Elhamel Background Laparoscopic cholecystectomy (LC) has an increased incidence of bile duct injury and bile leak when compared with open cholecystectomy. This study reviews management of these complications in a general hospital setting. Data collected from patients diagnosed and treated in one surgical unit for biliary complications after LC between 1992 and 1996 were analysed. Method A total of 14 patients were examined. Diagnosis was defined mainly by Endoscopic retrograde cholangiopancreatography (ERCP) and undetected choledocholitiasis was discovered in association with two of these complications. 43% of patients presented after LC with early postoperative bile leak or jaundice due to partial or complete bile duct excision or slippage of clips from the cystic duct. 57% presented with late biliary strictures. Thirteen patients were treated surgically, with biliary reconstruction (11 patients), direct repair (one) and cystic duct ligation in combination with clearance of bile duct from large multiple stones (one). One patient, who had clip displacement from cystic duct in combination with misplaced clip on right hepatic duct, was treated elsewhere. Postoperatively, one patient developed anastomotic leak and another died from sequellaie of bile duct transection requiring staged operations. Conclusions It is concluded that, in an environment similar to that where the authors had to work, LC should be performed in hospitals with facility to perform ERCP or when access for this technique is available in a nearby institution. Early recognition and immediate management of biliary injuries is dependent on individual resources and circumstances but, if required, consultation with colleagues or referral of patients with suspected or established biliary complications should not be delayed. [source] Minimally invasive management of bile leak after laparoscopic cholecystectomyHPB, Issue 2 2001G Tzovaras Background Bile leakage is an uncommon complication of cholecystectomy. The bile may originate from the gallbladder bed, the cystic duct or rarely from injury to a major bile duct. This study aims to evaluate the efficacy of minimal access endoscopic and percutaneous techniques in treating symptomatic bile leak. Patients and methods Twenty-one patients with symptomatic bile leak following laparoscopic cholecystectomy underwent assessment of the extent of the bile leak via ultrasound/CT and ERCP. Following diagnosis, the patients were treated by sphincterotomy and biliary drainage and, if necessary, percutaneous drainage of the bile collection. Results Only one patient required primary surgical treatment following diagnosis of a major duct injury. The other 20 were treated by a combination of sphincterotomy (including a stent in most) plus percutaneous drainage in six. In 19 of 20, this minimal access approach stopped the leak. Discussion Most patients who present with bile leakage after cholecystectomy can be managed successfully by means of ERCP with percutaneous drainage of any large bile collection. [source] Post-cholecystectomy biliary strictures: Not always benignJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 7pt2 2008Ajay Sharma Abstract Background:, Post-cholecystectomy malignant biliary obstruction masquerading as benign biliary stricture (BBS) has not been reported in the literature; it presents a diagnostic and management challenge. Methods:, Of the 349 post-cholecystectomy BBS managed at a tertiary care hospital in northern India between 1989 and 2004, 11 patients were found to have biliary malignancy. Records of these 11 patients were analyzed retrospectively for the purpose of this study. Results:, Mean age of patients with malignant biliary strictures was significantly higher (52 vs 38 years, P = 0.000); they were more likely to have jaundice (100% vs 78%, P = 0.008) and pruritus (82% vs 48%, P = 0.03). Unlike most patients with BBS referred from elsewhere to us, they had had a smooth postoperative course uncomplicated by bile leak, had a longer cholecystectomy-presentation interval, and were more likely to have high strictures ((Bismuth type III/IV) 91% vs 49%, P = 0.008). Conclusions:, Post-cholecystectomy biliary obstruction is not always benign. High bilirubin levels and hilar strictures, especially after an uneventful cholecystectomy, in a middle-aged patient should raise a suspicion of underlying missed malignancy. [source] Routine endoscopic retrograde cholangiography in the detection of early biliary complications after liver transplantationLIVER TRANSPLANTATION, Issue 5 2002Sudeep R. Shah The value of routinely performing endoscopic retrograde cholangiography (ERC) to detect biliary complications in patients undergoing orthotopic liver transplantation (OLT) with duct-to-duct anastomosis without a T-tube is not known. Eighty-nine of 171 liver transplant recipients (61 men; mean age, 49.9 years) underwent ERC 14.5 ± 4.5 (SD) days after surgery between January 1997 and August 1999. Findings of ERC and need for intervention for biliary complications were noted. ERC was successful in 71of 89 patients (80%). Nineteen patients (21%) required intervention for biliary complications (stricture, 13 patients; bile leak, 6 patients). Protocol ERC detected eight of these complications (42%). In 4 patients, ERC failed, and 7 patients with a normal ERC result subsequently required intervention (2 patients in the same admission, and 5 patients after discharge). Sensitivity, specificity, and positive and negative predictive values for successful ERC in detecting early biliary complications were 80%, 98%, 89%, and 97%, whereas those for predicting the overall rate of biliary complications were 53%, 98%, 89%, and 89%, respectively. Although highly specific and moderately sensitive in detecting early biliary complications, ERC performed routinely has low sensitivity in predicting the overall risk for biliary complications in patients undergoing OLT with unsplinted duct-to-duct anastomosis. [source] Reduced Size Liver Transplantation from a Donor Supported by a Berlin HeartAMERICAN JOURNAL OF TRANSPLANTATION, Issue 11 2009M. V. Misra Patients on cardiac assist devices are often considered to be high-risk solid organ donors. We report the first case of a reduced size liver transplant performed using the left lateral segment of a pediatric donor whose cardiac function was supported by a Berlin Heart. The recipient was a 22-day-old boy with neonatal hemochromatosis who developed fulminant liver failure shortly after birth. The transplant was complicated by mild delayed graft function, which required delayed biliary reconstruction and abdominal wall closure, as well as a bile leak. However, the graft function improved quickly over the first week and the patient was discharged home with normal liver function 8 weeks after transplant. The presence of a cardiac assist device should not be considered an absolute contraindication for abdominal organ donation. Normal organ procurement procedures may require alteration due to the unusual technical obstacles that are encountered when the donor has a cardiac assist device. [source] ROLE OF LAPAROSCOPY IN BLUNT LIVER TRAUMAANZ JOURNAL OF SURGERY, Issue 5 2006Charles H. C. Pilgrim Although much has been written about the role of laparoscopy in the acute setting for victims of blunt and penetrating trauma, little has been published on delayed laparoscopy relating specifically to complications of conservative management of liver trauma. There has been a shift towards managing liver trauma conservatively, with haemodynamic instability being the key indication for emergency laparotomy, rather than computed tomography findings. However, as a side-effect of more liver injuries being treated non-operatively, bile leak from a disrupted biliary tree presenting later in admission has appeared as a new problem to manage. We describe in this article three cases that have been managed by laparoscopy and drainage alone, outlining the advantages of this technique and defining a new role for delayed laparoscopy in blunt liver trauma. [source] Current practice in the management of acute cholecystitisBRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 3 2000I. C. Cameron Aims: Several recent papers have advocated emergency cholecystectomy for patients with acute cholecystitis, stating that it is safe, cost effective and leads to less time off work. This study was designed to assess current practice in the management of acute cholecystitis in the UK. Methods: A postal questionnaire was sent to 357 consultant surgeons who were thought to be involved in a general surgical on-call rota, to ascertain their current management of patients with acute cholecystitis. Replies were received from 250 consultants (70 per cent) of whom 242 (68 per cent) were involved in a general surgical take. Sixteen of these consultants, however, handed their patients with acute cholecystitis on to a different team the following day for further management. Results: Twenty-seven consultants (12 per cent) routinely treat their patients by emergency cholecystectomy whenever possible, with 24 stating that they would do this within 72 h. Limiting factors to this practice were stated to be availability of surgical staff (15), theatre space (nine) and radiological investigations (four). The remaining consultants (n = 199) routinely manage their patients conservatively initially and providing they settle, either (1) book directly for cholecystectomy (n = 94, 47 per cent), (2) reassess as an outpatient (n = 65, 33 per cent), (3) either of above (n = 21; 11 per cent) or (4) refer on to a colleague (n = 19, 10 per cent). The commonest indications for acute cholecystectomy stated by consultants whose initial treatment policy is conservative are spreading peritonitis due to bile leak (93 per cent), empyema (89 per cent), unexpected space on a theatre list (28 per cent) and failure of an acute episode to settle (21 per cent). The laparoscopic method is the commonest for both elective and emergency cholecystectomy, but the percentage of consultants using an open method rises dramatically from 9 per cent in the elective situation to 48 per cent for emergency cholecystectomy. Conclusions: Despite evidence to support the increased use of emergency cholecystectomy, this practice is routinely carried out by only 12 per cent of consultants. However, of the consultants who treat their patients conservatively, 28 per cent are prepared to undertake emergency cholecystectomy if an unexpected space appears on the theatre list. © 2000 British Journal of Surgery Society Ltd [source] Liver transplantation for sinusoidal obstructive syndrome (veno-occlusive disease): case report with review of the literature and the UNOS databaseCLINICAL TRANSPLANTATION, Issue 4 2008Fernando E. Membreno Abstract:,Background:, Severe sinusoidal obstructive syndrome (SOS) is a life-threatening complication of stem cell transplantation. We report the case of a young man transplanted for SOS. Method:, A single chart review with query of the United Network of Organ Sharing database and review of the medical literature. Case:, A 23-yr-old male diagnosed with chronic myeloid leukemia underwent a matched unrelated stem cell transplant. The conditioning regimen included high-dose cyclophosphamide and busulfan. Within one month, he developed painful hepatomegaly, jaundice, ascites, and weight gain, and was diagnosed with biopsy-proven SOS. Despite therapy with defibrotide, he continued to deteriorate with the development of progressive renal failure and encephalopathy. The patient underwent orthotopic liver transplantation. After surgery, he developed cytomegalovirus infection and six wk later presented with a bile leak, hepatic artery thrombosis, and a liver abscess. A repeat bone marrow biopsy showed no evidence of recurrent disease. Although the patient was listed for re-transplantation, he succumbed prior to an organ becoming available. Conclusion:, Severe SOS in the setting of bone marrow transplantation portends a poor prognosis. Careful patient selection, timing, and perhaps less immunosuppression should be considered when performing a liver transplantation in the setting of severe SOS. [source] Combined liver and inferior vena cava resection for hepatic malignancyJOURNAL OF SURGICAL ONCOLOGY, Issue 3 2007Spiros G. Delis MD Abstract Objective The experience from a single center, in combined liver and inferior vena cava (IVC) resection for liver tumors, is presented. Methods Twelve patients underwent a combined liver resection with IVC replacement. The median age was 45 years (range 35,67 years). Resections were carried out for hepatocellular carcinoma (n,=,4), colorectal metastases (n,=,6), and cholangiocarcinoma (n,=,2). Liver resections included eight right lobectomies and four left trisegmentectomies. The IVC was reconstructed with ringed Gore-Tex tube graft. Results No perioperative deaths were reported. The median operative blood transfusion requirement was 2 units (range 0,12 units) and the median operative time was 5 hr. Median hospital stay was 10 days (range 8,25 days). Three patients had evidence of postoperative liver failure, resolved with supportive management. Two patients developed bile leaks, resolved conservatively. With a median follow up of 24 months, all vascular reconstructions were patent and no evidence of graft infection was documented. Conclusions Aggressive surgical management of liver tumors, offer the only hope for cure or palliation. We suggest that liver resection with vena cava replacement may be performed safely, with acceptable morbidity, by specialized surgical teams. J. Surg. Oncol. 2007;96: 258,264. © 2007 Wiley-Liss, Inc. [source] Biliary tract injury in laparoscopic cholecystectomy: Results of a single unitANZ JOURNAL OF SURGERY, Issue 12 2002Michael Miroshnik Background: Laparoscopic cholecystectomy was introduced into Australia in early 1990. Its rapid increase in acceptance was, however, tempered by reports of an increased incidence of bile duct injury. The aim of this study was to report on the incidence of biliary tract injuries in a single unit, comment on the way they were managed and look at strategies to prevent them. Methods: A retrospective audit was conducted on laparoscopic cholecystectomies performed between January 1992 and March 2001. The data was collated from patient medical record files and yielded a total of 1216 procedures. Results: There were 899 women (74%) and 317 men (26%), with an age range of 13,92 years. Most of the procedures were performed on an elective (94%) rather than emergent basis (6%). There was one bile duct injury (0.09%) and seven bile leaks (0.63%). The single injury involved common bile duct obstruction by a misplaced clip and was successfully managed by cholangio-enteric bypass. Of the seven bile leaks, three were from the cystic duct stump, two from the gallbladder bed, and two were unidentified, settling conservatively. Of the five patients actively treated, two underwent therapeutic laparoscopy, two proceeded to laparotomy, and one was managed successfully by endoscopic stenting. Conclusions: Single-centre studies such as this are important in ensuring that standards of surgery are maintained in a community setting. [source] Role of relaparoscopy in the management of minor bile leakage after laparoscopic cholecystectomyBRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 2 2000V. L. Wills Background: Bile leakage in the absence of major ductal injury may occur from the liver bed or from the cystic duct remnant after cholecystectomy. The early limitations of minimally invasive surgery led to reliance on endoscopic methods to manage this complication. However, repeat laparoscopy permits drainage of the bile collection and direct control of the site of leakage in selected situations. Methods: Details of 15 patients with bile leakage after laparoscopic cholecystectomy were recorded prospectively and are reviewed. Results: Postoperative bile leakage occurred after 15 (0·8 per cent) of 1779 laparoscopic chole-cystectomies. Two patients with bile in drainage fluid had spontaneous resolution. Ten patients with a subvesical duct leak had repeat laparoscopy. The leak was successfully controlled by suturing in eight patients, and by a laparoscopically placed drain in two. One patient required a subsequent laparotomy for a loculated pelvic collection. Three patients had cystic duct stump leakage. This was managed successfully by laparoscopy in one case but required endoscopic management in two. Conclusion: Laparoscopy is useful in the management of minor bile leaks after laparoscopic chole-cystectomy. Selection of appropriate patients relies on a characteristic clinical presentation after an otherwise uncomplicated cholecystectomy. © 2000 British Journal of Surgery Society Ltd [source] Spatulated end-to-end bile duct reconstruction in orthotopic liver transplantationCLINICAL TRANSPLANTATION, Issue 1 2007Andrzej K Buczkowski Abstract:, Biliary complications continue to be a major source of morbidity following orthotopic liver transplantation. The aim of this study was to analyze the incidence and management of biliary complications related to the technique of bile duct reconstruction. The patients were stratified into two groups: group I (n = 39) had bile duct reconstruction performed by an end-to-end single interrupted suture choledochocholedochostomy (EE-CDCD) and group II (n = 38) had a spatulated end-to-end CDCD (spEE-CDCD) reconstruction; both groups had an intraductal stent. The groups were similar in age, gender, liver transplant indications and Pugh score. Ten biliary complications (26%), including five bile leaks (13%) and five biliary strictures (13%), were observed in the EE-CDCD group, while one biliary stricture (2.6%) occurred in the spEE-CDCD group (p < 0.05). Subsequent imaging studies and endoscopic retrograde cholangiopancreatography were performed less often in patients undergoing spEE-CDCD reconstruction (p < 0.05). The technique of a spatulated end-to-end bile duct reconstruction provides a significant improvement in lowering biliary complication rates in liver transplant patients. Despite the modest number of cases in this study this technique shows promise and has become the technique of choice in our institution. [source] | ||||||||||||||||||||||