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Leslie H. Blumgart - One of the best experts on this subject based on the ideXlab platform.

  • Management of the left Hepatic Duct during extended right hepatectomy
    Hpb, 2002
    Co-Authors: Jonathan B. Koea, Leslie H. Blumgart
    Abstract:

    Extended right Hepatic lobectomy involves the resection of segments IV to VIII and often includes resection of the caudate lobe (segment I). This resection is necessary to treat right-sided tumours that extend into segment IV. On occasion these tumours will extend to the umbilical fissure (Figure 1) and involve the left Hepatic Duct at the base of the fissure. This involvement has often been considered a contraindication to resection as mobilisation of tumour off the left Duct is technically difficult and may result in a positive margin. Unrecognised damage to the Duct may also present in the postoperative period with a biliary fistula. We report three patients who presented with massive right-sided tumours involving the left Hepatic Duct at the base of the umbilical fissure, on whom extended right hepatectomy was carried out in conjunction with resection and primary anastomosis of the left Duct. Figure 1.  Line drawing illustrating a tumour lying in the base of segment IV. Patients and operative technique Between 1992 and 2000, 1597 liver resections were performed in our unit. Of these, 393 were extended right hepatectomies. Three of these patients presented with massive right-sided tumours extending into the base of segment IV and involving the left Hepatic Duct at the base of the umbilical fissure. Their clinical details of these patients are shown in Table 1. Table 1. Summary of the clinical details of three patients treated with extended right hepatectomy and resection of the left Hepatic Duct for massive right-sided tumours All three patients had complete resection of the tumour. Extended right Hepatic lobectomy was undertaken with our reported technique 1. The liver was mobilised from the inferior vena cava dividing multiple small retroHepatic veins draining the caudate lobe. The right Hepatic vein was dissected under direct vision and was prepared for cross-clamping. The right Hepatic artery and portal vein branches divided extraHepatically in all patients. The umbilical fissure was opened, and all vascular and biliary branches to segments IVa and IVb were divided. The left Hepatic Duct was sectioned close to the base of the umbilical fissure, cephalad to the entry of the caudate Duct as caudate resection was not performed. The common Hepatic Duct was divided above the entry of the cystic Duct (Figure 2). Parenchymal division was undertaken using a crushing technique with inflow occlusion for periods of 5 minutes duration, with 5 minutes recovery. Figure 2.  Line drawing demonstrating the remaining segments II and III following extended right hepatectomy with caudate lobectomy. The left Hepatic Duct has been sectioned at the base of the umbilical fissure, and the common Hepatic Duct divided superior to the ... Reconstruction was undertaken by bringing the common Hepatic Duct upwards to the left Hepatic Duct and spatulating both ends of the Ducts. A single-layer anastomosis was constructed using interrupted 5-0 absorbable sutures (Figure 3, left). Individual sutures were placed in the anterior wall of the left Hepatic Duct leaving the needles on each suture. The posterior row of sutures was then placed, taking full-thickness bites of the common Hepatic Duct and left Hepatic Duct (Figure 3, middle). The corner sutures were tied but left long for retraction. Using the previously placed sutures in left Hepatic Duct, the anterior row was completed by taking full-thickness bites of the wall of the common Hepatic Duct (Figure 3, right). The anastomosis was stented in one patient (case no. 2), because of the small calibre of the Ducts, using a 5 fr silastic tube introduced through the right Hepatic Duct orifice. Ductal patency and anastomotic integrity were confirmed between 5 and 7 days postoperatively with a HIDA scan in all three patients. Figure 3.  Line drawing demonstratingthe technique used for anastomosis between the common Hepatic Duct and left bile Duct. An anterior row of 5-0 absorbable sutures are placed in the left bile Duct leaving needles on (left). A posterior layer of absorbable sutures ... Discussion Involvement of the left Hepatic Duct has been regarded by some as a contraindication to the performance of an extended right Hepatic resection. Certainly, involvement of the left Duct is an important hazard to the safe performance of this resection. Often, involvement of the left Duct at the base of the umbilical fissure is not demonstrated until after a trial dissection, and mobilisation of tumour off this structure can result in either a positive margin or damage and later biliary fistula. We report three patients in whom en bloc resection of the left Hepatic Duct with primary anastomosis between the common Hepatic and Ductal remnant was carried out with no adverse sequelae. It is important to emphasize that, in performing this technique, dissection and mobilisation of the left Duct must be carried out within the umbilical fissure to control it proximal and distal to the involved segment. If caudate lobectomy is not performed, care must be taken either to section the left Hepatic Duct caudad to the entry of the caudate Ducts or to incorporate these Ducts into the biliary repair. If this manoeuvure is not carried out, a biliary fistula is inevitable. Although all patients eventually died of recurrent Hepatic disease in this small series, hospital stay was relatively short and they all returned home. No patient developed a postoperative biliary stricture. The treatment options for patients with massive right-sided cancers involving the left Hepatic Duct are limited as they are, in general, unsuitable for ablative therapies and appreciable response following systemic chemotherapy is rare. In addition, many of these tumours have involved the right Hepatic inflow and are threatening the left Hepatic inflow, making death from Hepatic failure inevitable, if untreated. These patients provide a substantial surgical challenge, but this small series demonstrates that extended right hepatectomy is feasible, even when the left Duct is involved, and offers a chance to prevent early death from liver failure.

  • operative repair of bile Duct injuries involving the Hepatic Duct confluence
    Archives of Surgery, 1999
    Co-Authors: William R Jarnagin, Leslie H. Blumgart
    Abstract:

    Injuries at the Hepatic Duct confluence present the surgeon with a technically demanding repair, often combined with life-threatening sequelae such as sepsis and portal hypertension. Moreover, the possibility of litigation is ever present, even for those not responsible for the initial injury. In this review, we discuss the approach to patients with proximal bile Duct injuries, with emphasis on preoperative evaluation and the technical aspects of biliary reconstruction.

  • intraHepatic biliary enteric bypass provides effective palliation in selected patients with malignant obstruction at the Hepatic Duct confluence
    American Journal of Surgery, 1998
    Co-Authors: William R Jarnagin, Edmund C Burke, Christina Powers, Yuman Fong, Leslie H. Blumgart
    Abstract:

    Abstract Background: Palliating the effects of biliary obstruction is a major goal of therapy in patients with cancer at the Hepatic Duct confluence. This study was undertaken to evaluate the effectiveness of intraHepatic biliary-enteric bypass to either the segment III Duct or the right sectoral Hepatic Ducts in patients with unresectable hilar cholangiocarcinoma or gallbladder carcinoma. Methods: From December 1991 to October 1996, 55 consecutive bypass procedures were prospectively evaluated in patients with unresectable hilar cholangiocarcinoma or gallbladder cancer. Patients were divided into three groups based on the primary tumor and the type of bypass performed: group 1A, cholangiocarcinoma/segment III bypass (n = 20); group 1B, cholangiocarcinoma/right sectoral Hepatic Duct bypass (n = 14); group 2, gallbladder cancer/segment III bypass (n = 21). Results: Mean hospital stay (14 ± 2 days) and mean blood loss (629 ± 84 mL) were similar among the three groups. Perioperative death occurred in 6 patients (11%): 0 in group 1A, 3 each in groups 1B and 2. All survivors had relief of jaundice and pruritis after bypass. Complications occurred in 25 patients (45%). Preoperative transHepatic biliary drainage, performed in 14 patients prior to referral, was associated with a higher incidence of contaminated bile, greater operative blood loss, and postoperative biliary leak that was less likely to resolve spontaneously. Median survival in patients with cholangiocarcinoma (groups 1A and 1B) was 52 weeks and was unaffected by the type of bypass performed. By contrast, median survival in patients with gallbladder cancer (group 3) was 20 weeks; all but 3 died within 32 weeks of surgery. In patients with cholangiocarcinoma, the 1-year bypass patency was 80% in group 1A (segment III bypass) and 60% in group 1B (right sectoral Hepatic Duct bypass). Overall, there were 9 late bypass failures (18%) requiring reintervention. Conclusions: IntraHepatic biliary-enteric bypass effectively relieves symptoms due to malignant hilar obstruction. In patients with cholangiocarcinoma, segment III bypass provides excellent palliation with relatively few late complications and can be performed with minimal morbidity and mortality. Bypass to the right sectoral Hepatic Ducts, on the other hand, is associated with significant procedure-related morbidity and mortality and more late complications. Patients with gallbladder cancer, because of their poor survival, are probably better palliated by percutaneous biliary stenting.

Leslie Wise - One of the best experts on this subject based on the ideXlab platform.

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  • isolated right segmental Hepatic Duct injury a diagnostic and therapeutic challenge
    Journal of Gastrointestinal Surgery, 2000
    Co-Authors: Keith D Lillemoe, Jason A Petrofski, Michael A Choti, Anthony C Venbrux, John L. Cameron
    Abstract:

    Biliary leaks and injuries are not an uncommon occurrence following laparoscopic cholecystectomy. Bile leaks associated with the biliary anatomic variant of a low-inserting right segmentai Hepatic Duct can be particularly difficult to diagnose in that results of endoscopie retrograde cholangiography (ERC) are usually interpreted as ‘normal’ with no leaks demonstrated. The aim of this study was to describe a single institution’s experience with nine patients with biliary leaks associated with this anatomic variant and to discuss their management. A retrospective analysis of the hospital records of all patients with bile Duct injuries managed at a single institution between 1980 and July 1998, inclusive, was performed. Nine patients were identified as having an isolated right segmental Hepatic Duct injury associated with a biliary leak. Seven (78%) of the nine patients had undergone a laparoscopic cholccystcctomy, whereas the remaining two patients (22%) had undergone an open cholecystectomy. All of the patients had undergone endoscopie retrograde cholangiography at outside institutions, the results of which had been interpreted as normal with no apparent leaks. The median interval from the time of cholecystectomy to referral was 1.4 months. All patients were managed with initial percutaneous access of the involved right segmentai biliary system, with placement of a percutaneous transHepatic stent. After the biliary leak was controlled, all patients underwent Roux-en-Y Hepaticojejunostomy to the isolated biliary segment. All patients had an uncomplicated postoperative course. There were no postoperative anastomotic leaks. Postoperative stenting was maintained for a mean of 8 months. Six (67%) of the nine patients had a long-term successful outcome with minimal or no symptoms. In three patients, recurrent symptoms with pain and/or cholangitis developed at a mean of 34 months. All three patients underwent percutaneous cholangiography, which demonstrated an anastomotic stricture, and all were managed with percutaneous balloon dilatation with a successful outcome. Currently eight (89%) of the nine patients are asymptomatic, with a mean followup of 70.4 months (range 12 to 226 months). One patient had intermittent right upper quadrant pain with normal liver function tests but has not required intervention. Isolated right segmental Hepatic Ductal inlury with biliary leakage is an uncommon complication following laparoscopic cholecystectomy. A diagnostic dilemma is created by the presence of a bile leak with a normal endoscopie retrograde cholangiogram. Management begins with percutaneous access or the transected isolated Ductal system followed by reconstruction as a Roux-en-Y Hepaticojejunostomy.