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Miguel Ángel Mercado - One of the best experts on this subject based on the ideXlab platform.

  • Prognostic implications of preserved bile duct confluence after latrogenic injury
    Hepato-gastroenterology, 2020
    Co-Authors: Miguel Ángel Mercado, Carlos Chan, Héctor Orozco, Carlos A. Hinojosa, Eitan Podgaetz, Guillermo Ramos-gallardo, Raul Galvez-trevino, Magdalena Valdes-villarreal
    Abstract:

    Background/Aims: Biliary reconstruction is performed according to the level of the injury. A comparative study between patients in whom the biliary junction was preserved and another group where the biliary junction was not preserved was done. Methodology: A retrospective review of the biliary reconstructions performed at our institution after iatrogenic lesions between 1990-2002 was done. Postoperative outcome, functional status of the anastomosis, recurrent cholangitis, need for radiological instrumentation and/or reoperation were analyzed. Results: We reviewed 204 cases, 130 cases had a preserved biliary junction while in 74 the injury included the junction. All patients were treated with a Roux-en-Y Hepatojejunostomy. In the first group, 4% required reoperation, 4% underwent radiological percutaneous instrumentation, 8% had anastomotic dysfunction and 4% cholangitis. In the second group, 24% needed reoperation and 80% radiological instrumentation. Anastomotic dysfunction was observed in 64% and cholangitis in 55%. It is important to note that 52 of the 74 cases in the second group had a history of more than two reconstruction attempts. Conclusions: When the biliary junction is preserved after a iatrogenic injury we found a significantly better outcome. The results of biliary reconstruction in this type of patient are better long-term compared to those where the junction was not preserved, evidenced by a lower reoperation and radiological instrumentation rate.

  • Bile duct injuries related to misplacement of “T tubes”
    Annals of Hepatology, 2020
    Co-Authors: Miguel Ángel Mercado, Carlos Chan, Ismael Domínguez, Héctor Orozco, Barajas Olivas, José Manuel Villalta, Javier Eraña, Fernando Poucel
    Abstract:

    Introduction: T tubes can be placed in the bile ducts either open or laparoscopically for several reasons such as: extraction of stones, biliary reconstruction after liver transplant and in end-to-end anastomosis in iatrogenic injuries. Inadequate placement of the T tube, long term stay and technical difficulties that can affect the outcome, can lead to an injury that usually requires a biliodigestive reconstruction. Methods: In a 15-year period (1990–2005) a total of 343 patients have been referred to our university hospital for biliary reconstruction. Files of those patients in which the injury was due to misplacement of a T tube or associated with a long-term stay were reviewed. We evaluated the type of injury, technique used for the reconstruction, longterm staying of the T tubes (1–6 months), hospital in stay, long term outcomes as well as associated comorbidities. Results: In 42 cases a biliary injury related to a T tube was identified (13%). All the injuries were classified as Strasberg E, with demonstration of a fistula (internal or external); 18 to the duodenum, 5 to the jejunum – ileum and 3 to the colon. A Hepatojejunostomy was done to all patients; the duodenum and small gut fistulas were closed and in the 3 cases with colonic injury a right hemicolectomy was performed. The postoperative evolution was adequate without major complications but with a longer hospital stay. In 39 of the 42 patients (92%), good postoperative results were obtained. Only one case required a new surgery (22 months after the first one), due to recidivant cholangitis. Conclusion: Inadequate placement of the T tubes and long-term stay can produce complex biliary

  • Iatrogenic bile duct injury with loss of confluence.
    World Journal of Gastrointestinal Surgery, 2015
    Co-Authors: Miguel Ángel Mercado, Mario Vilatobá, Alan G. Contreras, Pilar Leal-leyte, Eduardo Cervantes-alvarez, Juan-carlos Arriola, Bruno-adonai Gonzalez
    Abstract:

    AIM: To describe our experience concerning the surgical treatment of Strasberg E-4 (Bismuth IV) bile duct injuries. METHODS: In an 18-year period, among 603 patients referred to our hospital for surgical treatment of complex bile duct injuries, 53 presented involvement of the hilar confluence classified as Strasberg E4 injuries. Imagenological studies, mainly magnetic resonance imaging showed a loss of confluence. The files of these patients were analyzed and general data were recorded, including type of operation and postoperative outcome with emphasis on postoperative cholangitis, liver function test and quality of life. The mean time of follow-up was of 55.9 ± 52.9 mo (median = 38.5, minimum = 2, maximum = 181.2). All other patients with Strasberg A, B, C, D, E1, E2, E3, or E5 biliary injuries were excluded from this study. RESULTS: Patients were divided in three groups: G1 (n = 21): Construction of neoconfluence + Roux-en-Y Hepatojejunostomy. G2 (n = 26): Roux-en-Y portoenterostomy. G3 (n = 6): Double (right and left) Roux-en-Y Hepatojejunostomy. Cholangitis was recorded in two patients in group 1, in 14 patients in group 2, and in one patient in group 3. All of them required transhepatic instrumentation of the anastomosis and six patients needed live transplantation. CONCLUSION: Loss of confluence represents a surgical challenge. There are several treatment options at different stages. Roux-en-Y bilioenteric anastomosis (neoconfluence, double-barrel anastomosis, portoenterostomy) is the treatment of choice, and when it is technically possible, building of a neoconfluence has better outcomes. When liver cirrhosis is shown, liver transplantation is the best choice.

  • Classification and management of bile duct injuries.
    World Journal of Gastrointestinal Surgery, 2011
    Co-Authors: Miguel Ángel Mercado, Ismael Domínguez
    Abstract:

    To review the classification and general guidelines for treatment of bile duct injury patients and their long term results. In a 20-year period, 510 complex circumferential injuries have been referred to our team for repair at the Instituto Nacional de Ciencias Medicas y Nutricion “Salvador Zubiran” hospital in Mexico City and 198 elsewhere (private practice). The records at the third level Academic University Hospital were analyzed and divided into three periods of time: GI-1990-99 (33 cases), GII- 2000-2004 (139 cases) and GIII- 2004-2008 (140 cases). All patients were treated with a Roux en Y Hepatojejunostomy. A decrease in using transanastomotic stents was observed (78% vs 2%, P = 0.0001). Partial segment IV and V resection was more frequently carried out (45% vs 75%, P = 0.2) (to obtain a high bilioenteric anastomosis). Operative mortality (3% vs 0.7%, P = 0.09), postoperative cholangitis (54% vs 13%, P = 0.0001), anastomosis strictures (30% vs 5%, P = 0.0001), short and long term complications and need for reoperation (surgical or radiological) (45% vs 11%, P = 0.0001) were significantly less in the last period. The authors concluded that transition to a high volume center has improved long term results for bile duct injury repair. Even interested and tertiary care centers have a learning curve.

  • Intrahepatic Bilioenteric Anastomosis After Biliary Complications of Liver Transplantation: Operative Rescue of Surgical Failures
    World Journal of Surgery, 2009
    Co-Authors: Miguel Ángel Mercado, Mario Vilatobá, Carlos Chan, Ismael Domínguez, Rafael Paulino Leal, Marco Antonio Olivera
    Abstract:

    Background Biliary complications after orthotopic liver transplantation (OLT) are multifactorial in origin. In most series, the frequency of such complications ranges from 5–20%. Most can be treated by endoscopy and/or interventional radiology. For cases in which this option is not successful, surgical approach is indicated. We report the results of reoperation using an intrahepatic bilioenteric anastomosis. Methods The medical charts of patients with biliary complications after OLT during a 10-year period (1997–2007), who failed to respond to nonsurgical treatment and were surgically treated, were reviewed. Roux-en-Y Hepatojejunostomy was performed. Segments IV and V were partially removed after cutting the hilar plate, thus obtaining healthy ducts without ischemic or inflammatory reaction and allowing a wide Hepatojejunostomy. Results Five cases (8.4%) with biliary complications after duct-to-duct anastomosis not amenable to further endoscopic management or interventional radiology were identified. Hepaticojejunostomy was achieved in all cases (wide, tension-free, nonischemic, fine hydrolyzable sutures), and segments IV and V were partially removed. No cholangitis, jaundice, and liver function test abnormalities were present in the postoperative. Mean follow-up was 24 months. Only one patient died of causes not related to bile duct reconstruction during follow-up. Conclusions Intrahepatic Hepatojejunostomy with partial resection of segments IV and V offers an excellent therapeutic alternative for biliary complications that require a surgical approach after OLT.

Carlos Chan - One of the best experts on this subject based on the ideXlab platform.

  • Bile duct injuries related to misplacement of “T tubes”
    Annals of Hepatology, 2020
    Co-Authors: Miguel Ángel Mercado, Carlos Chan, Ismael Domínguez, Héctor Orozco, Barajas Olivas, José Manuel Villalta, Javier Eraña, Fernando Poucel
    Abstract:

    Introduction: T tubes can be placed in the bile ducts either open or laparoscopically for several reasons such as: extraction of stones, biliary reconstruction after liver transplant and in end-to-end anastomosis in iatrogenic injuries. Inadequate placement of the T tube, long term stay and technical difficulties that can affect the outcome, can lead to an injury that usually requires a biliodigestive reconstruction. Methods: In a 15-year period (1990–2005) a total of 343 patients have been referred to our university hospital for biliary reconstruction. Files of those patients in which the injury was due to misplacement of a T tube or associated with a long-term stay were reviewed. We evaluated the type of injury, technique used for the reconstruction, longterm staying of the T tubes (1–6 months), hospital in stay, long term outcomes as well as associated comorbidities. Results: In 42 cases a biliary injury related to a T tube was identified (13%). All the injuries were classified as Strasberg E, with demonstration of a fistula (internal or external); 18 to the duodenum, 5 to the jejunum – ileum and 3 to the colon. A Hepatojejunostomy was done to all patients; the duodenum and small gut fistulas were closed and in the 3 cases with colonic injury a right hemicolectomy was performed. The postoperative evolution was adequate without major complications but with a longer hospital stay. In 39 of the 42 patients (92%), good postoperative results were obtained. Only one case required a new surgery (22 months after the first one), due to recidivant cholangitis. Conclusion: Inadequate placement of the T tubes and long-term stay can produce complex biliary

  • Prognostic implications of preserved bile duct confluence after latrogenic injury
    Hepato-gastroenterology, 2020
    Co-Authors: Miguel Ángel Mercado, Carlos Chan, Héctor Orozco, Carlos A. Hinojosa, Eitan Podgaetz, Guillermo Ramos-gallardo, Raul Galvez-trevino, Magdalena Valdes-villarreal
    Abstract:

    Background/Aims: Biliary reconstruction is performed according to the level of the injury. A comparative study between patients in whom the biliary junction was preserved and another group where the biliary junction was not preserved was done. Methodology: A retrospective review of the biliary reconstructions performed at our institution after iatrogenic lesions between 1990-2002 was done. Postoperative outcome, functional status of the anastomosis, recurrent cholangitis, need for radiological instrumentation and/or reoperation were analyzed. Results: We reviewed 204 cases, 130 cases had a preserved biliary junction while in 74 the injury included the junction. All patients were treated with a Roux-en-Y Hepatojejunostomy. In the first group, 4% required reoperation, 4% underwent radiological percutaneous instrumentation, 8% had anastomotic dysfunction and 4% cholangitis. In the second group, 24% needed reoperation and 80% radiological instrumentation. Anastomotic dysfunction was observed in 64% and cholangitis in 55%. It is important to note that 52 of the 74 cases in the second group had a history of more than two reconstruction attempts. Conclusions: When the biliary junction is preserved after a iatrogenic injury we found a significantly better outcome. The results of biliary reconstruction in this type of patient are better long-term compared to those where the junction was not preserved, evidenced by a lower reoperation and radiological instrumentation rate.

  • Intrahepatic Bilioenteric Anastomosis After Biliary Complications of Liver Transplantation: Operative Rescue of Surgical Failures
    World Journal of Surgery, 2009
    Co-Authors: Miguel Ángel Mercado, Mario Vilatobá, Carlos Chan, Ismael Domínguez, Rafael Paulino Leal, Marco Antonio Olivera
    Abstract:

    Background Biliary complications after orthotopic liver transplantation (OLT) are multifactorial in origin. In most series, the frequency of such complications ranges from 5–20%. Most can be treated by endoscopy and/or interventional radiology. For cases in which this option is not successful, surgical approach is indicated. We report the results of reoperation using an intrahepatic bilioenteric anastomosis. Methods The medical charts of patients with biliary complications after OLT during a 10-year period (1997–2007), who failed to respond to nonsurgical treatment and were surgically treated, were reviewed. Roux-en-Y Hepatojejunostomy was performed. Segments IV and V were partially removed after cutting the hilar plate, thus obtaining healthy ducts without ischemic or inflammatory reaction and allowing a wide Hepatojejunostomy. Results Five cases (8.4%) with biliary complications after duct-to-duct anastomosis not amenable to further endoscopic management or interventional radiology were identified. Hepaticojejunostomy was achieved in all cases (wide, tension-free, nonischemic, fine hydrolyzable sutures), and segments IV and V were partially removed. No cholangitis, jaundice, and liver function test abnormalities were present in the postoperative. Mean follow-up was 24 months. Only one patient died of causes not related to bile duct reconstruction during follow-up. Conclusions Intrahepatic Hepatojejunostomy with partial resection of segments IV and V offers an excellent therapeutic alternative for biliary complications that require a surgical approach after OLT.

  • Intrahepatic Bilioenteric Anastomosis After Biliary Complications of Liver Transplantation: Operative Rescue of Surgical Failures
    World Journal of Surgery, 2009
    Co-Authors: Miguel Ángel Mercado, Mario Vilatobá, Carlos Chan, Ismael Domínguez, Rafael Leal, Marco Antonio Olivera
    Abstract:

    Biliary complications after orthotopic liver transplantation (OLT) are multifactorial in origin. In most series, the frequency of such complications ranges from 5–20%. Most can be treated by endoscopy and/or interventional radiology. For cases in which this option is not successful, surgical approach is indicated. We report the results of reoperation using an intrahepatic bilioenteric anastomosis. The medical charts of patients with biliary complications after OLT during a 10-year period (1997–2007), who failed to respond to nonsurgical treatment and were surgically treated, were reviewed. Roux-en-Y Hepatojejunostomy was performed. Segments IV and V were partially removed after cutting the hilar plate, thus obtaining healthy ducts without ischemic or inflammatory reaction and allowing a wide Hepatojejunostomy. Five cases (8.4%) with biliary complications after duct-to-duct anastomosis not amenable to further endoscopic management or interventional radiology were identified. Hepaticojejunostomy was achieved in all cases (wide, tension-free, nonischemic, fine hydrolyzable sutures), and segments IV and V were partially removed. No cholangitis, jaundice, and liver function test abnormalities were present in the postoperative. Mean follow-up was 24 months. Only one patient died of causes not related to bile duct reconstruction during follow-up. Intrahepatic Hepatojejunostomy with partial resection of segments IV and V offers an excellent therapeutic alternative for biliary complications that require a surgical approach after OLT.

  • Voluntary and Involuntary Ligature of the Bile Duct in Iatrogenic Injuries: A Nonadvisable Approach
    Journal of Gastrointestinal Surgery, 2008
    Co-Authors: Miguel Ángel Mercado, Carlos Chan, Norberto Sánchez, Juan Carlos Jacinto, Alexandra Barajas
    Abstract:

    Background Bile duct injuries related to laparoscopic and/or open cholecystectomy are a frequent finding and require surgical treatment. Complete obstruction is due to either intentionally or unintentionally placed ligatures or clips. The intentional application is usually performed to “facilitate identification of the duct by bile duct dilation.” Considering that we are a national referral center for such injuries, we decided to analyze our cases of voluntary and involuntary duct ligation after iatrogenic bile duct injury. Methods We reviewed the files of patients with voluntary or involuntary bile duct ligation. Results of preoperative evaluation of the ducts, operative treatment, and postoperative results were analyzed. Results A total of 413 patients were included. Forty-five patients presented with complete obstruction. In 15 cases, the ligature was intentional, and in 30 cases, occlusion was involuntary. Bile duct dilation (>10 mm) was demonstrated in one case of voluntary (6%) and three cases of involuntary ligations (10%). The remaining cases in both groups had no duct dilation and developed necrosis at the blinded duct and leakage proximal to the ligature, with different degrees of bilioperitoneum and/or biloma. In all cases, a Roux-en-Y Hepatojejunostomy was performed. Conclusion Bile duct ligature produces dilation in a very small number of patients (less than 10%) and usually produces necrosis of the blinded stump with subsequent bile leakage. Placement of a subhepatic drain and transference of the patient to a qualified center for reconstruction is the best approach if the primary surgeon is not able to do the repair.

Fabio Makdissi - One of the best experts on this subject based on the ideXlab platform.

  • Robotic Left Hepatectomy and Roux-en-Y Hepaticojejunostomy After Bile Duct Injury
    Annals of Surgical Oncology, 2019
    Co-Authors: Marcel Autran Machado, Rodrigo C. Surjan, Andre O. Ardengh, Fabio Makdissi
    Abstract:

    Background Bile duct injuries after cholecystectomy remain a major concern because their incidence has not changed through the years despite technical advances. This video presents a robotic left hepatectomy and Roux-en-Y hepaticojejunostomy as a treatment for a complex bile duct injury after laparoscopic cholecystectomy. Methods A 52-year-old man underwent laparoscopic cholecystectomy at another institution 8 years previously, which resulted in a bile duct injury. His postoperative period was complicated by jaundice and cholangitis. He was treated with endoscopic retrograde cholangiopancreatography and multiple endoprostheses for 3 years, after which the endoprostheses were removed, and he was sent to the authors’ institution. Computed tomography showed that the left liver had signs of disturbed perfusion and dilation of the left intrahepatic bile duct. The patient was asymptomatic and refused any further attempt at surgical correction of the lesion. He was accompanied for 5 years. Magnetic resonance imaging showed progressive atrophy of the left liver. Finally, 3 months before this writing, he presented with intermittent episodes of cholangitis. A multidisciplinary team decided to perform left hepatectomy with Roux-en-Y Hepatojejunostomy via a robotic approach. The left liver was atrophied, and left hepatectomy was performed. Fluorescence imaging was used to identify the right bile duct. At opening of the right bile duct, small stones were found and removed. Antecolic Roux-en-Y hepaticojejunostomy then was performed. Results The operative time was 335 min. Recovery was uneventful, and the patient was discharged on postoperative day 4. Conclusions Robotic repair of bile duct injuries is feasible and safe, even when liver resection is necessary. This video may help oncologic surgeons to perform this complex procedure.

  • Robotic Left Hepatectomy and Roux-en-Y Hepaticojejunostomy After Bile Duct Injury.
    Annals of Surgical Oncology, 2019
    Co-Authors: Marcel Autran C. Machado, Rodrigo C. Surjan, Andre O. Ardengh, Fabio Makdissi
    Abstract:

    Bile duct injuries after cholecystectomy remain a major concern because their incidence has not changed through the years despite technical advances. This video presents a robotic left hepatectomy and Roux-en-Y hepaticojejunostomy as a treatment for a complex bile duct injury after laparoscopic cholecystectomy. A 52-year-old man underwent laparoscopic cholecystectomy at another institution 8 years previously, which resulted in a bile duct injury. His postoperative period was complicated by jaundice and cholangitis. He was treated with endoscopic retrograde cholangiopancreatography and multiple endoprostheses for 3 years, after which the endoprostheses were removed, and he was sent to the authors’ institution. Computed tomography showed that the left liver had signs of disturbed perfusion and dilation of the left intrahepatic bile duct. The patient was asymptomatic and refused any further attempt at surgical correction of the lesion. He was accompanied for 5 years. Magnetic resonance imaging showed progressive atrophy of the left liver. Finally, 3 months before this writing, he presented with intermittent episodes of cholangitis. A multidisciplinary team decided to perform left hepatectomy with Roux-en-Y Hepatojejunostomy via a robotic approach. The left liver was atrophied, and left hepatectomy was performed. Fluorescence imaging was used to identify the right bile duct. At opening of the right bile duct, small stones were found and removed. Antecolic Roux-en-Y hepaticojejunostomy then was performed. The operative time was 335 min. Recovery was uneventful, and the patient was discharged on postoperative day 4. Robotic repair of bile duct injuries is feasible and safe, even when liver resection is necessary. This video may help oncologic surgeons to perform this complex procedure.

Marco Antonio Olivera - One of the best experts on this subject based on the ideXlab platform.

  • Intrahepatic Bilioenteric Anastomosis After Biliary Complications of Liver Transplantation: Operative Rescue of Surgical Failures
    World Journal of Surgery, 2009
    Co-Authors: Miguel Ángel Mercado, Mario Vilatobá, Carlos Chan, Ismael Domínguez, Rafael Paulino Leal, Marco Antonio Olivera
    Abstract:

    Background Biliary complications after orthotopic liver transplantation (OLT) are multifactorial in origin. In most series, the frequency of such complications ranges from 5–20%. Most can be treated by endoscopy and/or interventional radiology. For cases in which this option is not successful, surgical approach is indicated. We report the results of reoperation using an intrahepatic bilioenteric anastomosis. Methods The medical charts of patients with biliary complications after OLT during a 10-year period (1997–2007), who failed to respond to nonsurgical treatment and were surgically treated, were reviewed. Roux-en-Y Hepatojejunostomy was performed. Segments IV and V were partially removed after cutting the hilar plate, thus obtaining healthy ducts without ischemic or inflammatory reaction and allowing a wide Hepatojejunostomy. Results Five cases (8.4%) with biliary complications after duct-to-duct anastomosis not amenable to further endoscopic management or interventional radiology were identified. Hepaticojejunostomy was achieved in all cases (wide, tension-free, nonischemic, fine hydrolyzable sutures), and segments IV and V were partially removed. No cholangitis, jaundice, and liver function test abnormalities were present in the postoperative. Mean follow-up was 24 months. Only one patient died of causes not related to bile duct reconstruction during follow-up. Conclusions Intrahepatic Hepatojejunostomy with partial resection of segments IV and V offers an excellent therapeutic alternative for biliary complications that require a surgical approach after OLT.

  • Intrahepatic Bilioenteric Anastomosis After Biliary Complications of Liver Transplantation: Operative Rescue of Surgical Failures
    World Journal of Surgery, 2009
    Co-Authors: Miguel Ángel Mercado, Mario Vilatobá, Carlos Chan, Ismael Domínguez, Rafael Leal, Marco Antonio Olivera
    Abstract:

    Biliary complications after orthotopic liver transplantation (OLT) are multifactorial in origin. In most series, the frequency of such complications ranges from 5–20%. Most can be treated by endoscopy and/or interventional radiology. For cases in which this option is not successful, surgical approach is indicated. We report the results of reoperation using an intrahepatic bilioenteric anastomosis. The medical charts of patients with biliary complications after OLT during a 10-year period (1997–2007), who failed to respond to nonsurgical treatment and were surgically treated, were reviewed. Roux-en-Y Hepatojejunostomy was performed. Segments IV and V were partially removed after cutting the hilar plate, thus obtaining healthy ducts without ischemic or inflammatory reaction and allowing a wide Hepatojejunostomy. Five cases (8.4%) with biliary complications after duct-to-duct anastomosis not amenable to further endoscopic management or interventional radiology were identified. Hepaticojejunostomy was achieved in all cases (wide, tension-free, nonischemic, fine hydrolyzable sutures), and segments IV and V were partially removed. No cholangitis, jaundice, and liver function test abnormalities were present in the postoperative. Mean follow-up was 24 months. Only one patient died of causes not related to bile duct reconstruction during follow-up. Intrahepatic Hepatojejunostomy with partial resection of segments IV and V offers an excellent therapeutic alternative for biliary complications that require a surgical approach after OLT.

Hans J. Schlitt - One of the best experts on this subject based on the ideXlab platform.

  • Biliodigestive Anastomosen: Indikationen, Komplikationen und interdisziplinäres Management
    Chirurg, 2012
    Co-Authors: H. Goessmann, Hans J. Schlitt, Sven A. Lang, Stefan Fichtner-feigl, Marcus N. Scherer, Christian Stroszczynski, Andreas G. Schreyer, Andreas A. Schnitzbauer
    Abstract:

    Techniques for biliodigestive anastomoses are a frequent indication in primary surgical interventions. Moreover, they are required to manage secondary complications of hepatobiliary surgery. Evidence for the management of complications following biliodigestive anastomoses is low. Biliodigestive anastomoses can be performed as hepaticojejunostomy, Hepatojejunostomy/portoenterostomy and hepaticoduodenostomy using running or single stitch suture techniques. Complication management in the hands of experienced hepatopancreatobiliary surgeons should consider a time delay to the primary operation and an interdisciplinary surgical and/or endoscopic or radiologic interventional approach. The therapy may be protracted and requires repeated critical reflection of the particular complication.

  • Effectiveness of Peripheral Hepatogastrostomy Versus Hepatojejunostomy in the Treatment of Obstructive Cholestasis: Results of an Experimental Model
    Surgery Today, 2004
    Co-Authors: Marc H. Dahlke, Heiko Aselmann, Dilek Ceylan, Tobias Bellin, Peer Flemming, Peter N. Meier, Karl Oldhafer, Juergen Klempnauer, Hans J. Schlitt, Pompiliu Piso
    Abstract:

    Tumors of the liver hilum frequently cause obstructive cholestasis. When a curative resection of the tumor is impossible, palliative bile drainage is indicated. A Hepatojejunostomy is performed if conservative treatment fails or if irresectability is proven during an initial laparotomy. In patients with peritoneal carcinosis and mesentery retraction, a hepatogastrostomy may represent a helpful alternative. An experimental study was designed to compare the bile drainage effectiveness of a hepatogastrostomy versus a Hepatojejunostomy. Methods Two-month-old outbred piglets were used in all experiments. The animals were randomized into three groups (Hepatojejunostomy, hepatogastrostomy alone, hepatogastrostomy and proton pump inhibitors). Obstructive cholestasis was induced by common bile duct ligation; Hepatojejunostomy and hepatogastrostomy were performed 2 weeks later. The serum bilirubin levels were monitored weekly. All animals were killed 4 weeks after the drainage operation. Results Following a Hepatojejunostomy ( n = 5) all animals showed decreasing cholestasis parameters. All animals ( n = 3) died within 3–5 days after a hepatogastrostomy due to gastrointestinal bleeding caused by gastric ulcers and ulcers of the liver surface. The administration of pantoprazole prevented these bleeding complications. In animals treated by hepatogastrostomy and proton pump inhibitors ( n = 5), bile drainage effectiveness was similar to that following Hepatojejunostomy. Conclusion A hepatogastrostomy represents an alternative treatment option for surgical bile drainage with a similar effectiveness to that of a Hepatojejunostomy. To prevent postoperative gastrointestinal bleeding, proton pump inhibitors should be used.

  • effectiveness of peripheral hepatogastrostomy versus Hepatojejunostomy in the treatment of obstructive cholestasis results of an experimental model
    Surgery Today, 2004
    Co-Authors: Marc H. Dahlke, Heiko Aselmann, Dilek Ceylan, Tobias Bellin, Peer Flemming, Peter N. Meier, Karl Oldhafer, Juergen Klempnauer, Hans J. Schlitt, Pompiliu Piso
    Abstract:

    Tumors of the liver hilum frequently cause obstructive cholestasis. When a curative resection of the tumor is impossible, palliative bile drainage is indicated. A Hepatojejunostomy is performed if conservative treatment fails or if irresectability is proven during an initial laparotomy. In patients with peritoneal carcinosis and mesentery retraction, a hepatogastrostomy may represent a helpful alternative. An experimental study was designed to compare the bile drainage effectiveness of a hepatogastrostomy versus a Hepatojejunostomy. Two-month-old outbred piglets were used in all experiments. The animals were randomized into three groups (Hepatojejunostomy, hepatogastrostomy alone, hepatogastrostomy and proton pump inhibitors). Obstructive cholestasis was induced by common bile duct ligation; Hepatojejunostomy and hepatogastrostomy were performed 2 weeks later. The serum bilirubin levels were monitored weekly. All animals were killed 4 weeks after the drainage operation. Following a Hepatojejunostomy (n = 5) all animals showed decreasing cholestasis parameters. All animals (n = 3) died within 3–5 days after a hepatogastrostomy due to gastrointestinal bleeding caused by gastric ulcers and ulcers of the liver surface. The administration of pantoprazole prevented these bleeding complications. In animals treated by hepatogastrostomy and proton pump inhibitors (n = 5), bile drainage effectiveness was similar to that following Hepatojejunostomy. A hepatogastrostomy represents an alternative treatment option for surgical bile drainage with a similar effectiveness to that of a Hepatojejunostomy. To prevent postoperative gastrointestinal bleeding, proton pump inhibitors should be used.

  • Reconstructive surgery for ischemic-type lesions at the bile duct bifurcation after liver transplantation.
    Annals of Surgery, 1999
    Co-Authors: Hans J. Schlitt, Peter N. Meier, Karl Oldhafer, Bjorn Nashan, Rudolf Raab, Klaus H.w. Boeker, P. Flemming, Michael P. Manns, Rudolf Pichlmayr
    Abstract:

    Objective To assess the feasibility, morbidity, mortality, and clinical success rate of surgical reconstruction of the biliary system in patients with ischemic-type biliary lesions in their liver graft. Summary Background Data After liver transplantation, strictures in the biliary tree with secondary sludge formation can occur in the absence of vascular problems. Jaundice, pruritus, and recurrent cholangitis are predominant clinical features leading to considerable morbidity. Interventional measures are the first-line treatment but are frequently only of transient success. Retransplantation is usually considered when interventional treatment is not effective. Methods Surgical exploration and reconstruction was performed in 17 patients with ischemic-type biliary strictures at a median of 2 years after liver transplantation. Findings during surgery, surgical strategies, and postsurgical courses are described. Clinical symptoms and biochemical parameters of cholestasis and liver function were analyzed in the postsurgical course. Results During surgery, all 17 patients were found to have strictures or sclerotic changes involving the hepatic bifurcation and extrahepatic bile duct. Sludge or stones were present in nine patients. In 14 patients with viable bile ducts proximal to the bifurcation, surgical reconstruction was performed by resection of the bifurcation and hepaticojejunostomy. In three patients with more extensive biliary destruction, portoenterostomy with or without peripheral Hepatojejunostomy was performed. The prevalence rate of biliary infection at surgery was 93%; the predominant organisms were Candida and enterococci. The perioperative mortality rate was 0%. Clinical symptoms and biochemical parameters became normal or were considerably improved in 14 of 16 patients (88%). Conclusions The hepatic bifurcation seems to be a predominant site for ischemic-type biliary changes after liver transplantation. Surgical treatment by resection of the bifurcation and reconstruction by high hepaticojejunostomy is a safe and highly effective approach leading to cure or persistent major improvement in most patients.

  • peripheral Hepatojejunostomy as palliative treatment for irresectable malignant tumors of the liver hilum
    Annals of Surgery, 1999
    Co-Authors: Hans J. Schlitt, Karl Oldhafer, Arved Weimann, Jurgen Klempnauer, Bjorn Nashan, Rudolf Raab, R Pichlmayr
    Abstract:

    OBJECTIVE: To evaluate the concept of surgical decompression of the biliary tree by peripheral Hepatojejunostomy for palliative treatment of jaundice in patients with irresectable malignant tumors of the liver hilum. SUMMARY BACKGROUND DATA: Jaundice, pruritus, and recurrent cholangitis are major clinical complications in patients with obstructive cholestasis resulting from malignant tumors of the liver hilum. Methods for palliative treatment include endoscopic stenting, percutaneous transhepatic drainage, and surgical decompression. The palliative treatment of choice should be safe, effective, and comfortable for the patient. METHODS: In a retrospective study, surgical technique, perioperative complications, and efficacy of treatment were analyzed for 56 patients who had received a peripheral Hepatojejunostomy between 1982 and 1997. Laparotomy in all of these patients had been performed as an attempt for curative resection. RESULTS: Hepatojejunostomy was exclusively palliative in 50 patients and was used for bridging to resection or transplantation in 7. Anastomosis was bilateral in 36 patients and unilateral in 20. The 1-month mortality in the study group was 9%; median survival was 6 months. In patients surviving >1 month, a marked and persistent decrease in cholestasis was achieved in 87%, although complete return to normal was rare. Among the patients with a marked decrease in cholestasis, 72% had no or only mild clinical symptoms such as fever or jaundice. CONCLUSIONS: Peripheral Hepatojejunostomy is a feasible and reasonably effective palliative treatment for patients with irresectable tumors of the liver hilum. In patients undergoing exploratory laparotomy for attempted curative resection, this procedure frequently leads to persistent-although rarely complete-decompression of the biliary tree. In a few cases it may also be used for bridging to transplantation or liver resection after relief of cholestasis.