LIVER TRANSPLANTATION 21:561–563, 2015
LETTER FROM THE FRONTLINE
Pure Laparoscopic Management of Early Biliary Leakage After Liver Transplantation: Abdominal Lavage and T-Tube Placement Received November 29, 2014; accepted December 18, 2014.
TO THE EDITORS: Leakage is the second most frequent biliary complication (after anastomotic strictures) after liver transplantation (LT). Although the therapeutic approach is centerspecific and must be tailored to every patient’s circumstances, endoscopic retrograde cholangiography (ERCP) is usually the therapy of choice and has high success rates.1 Nevertheless, surgical revision may be indicated, particularly when large defects or severe peritonitis is observed. We present the case of an anastomotic biliary leakage with associated diffuse biliary peritonitis after LT that was successfully treated with a totally laparoscopic approach. It involved thorough abdominal lavage and leakage repair by T-tube placement. Laparoscopic surgery is a widely accepted approach in several surgical fields because it is advantageous in terms of postoperative recovery. In the postoperative course after LT, this minimally invasive approach not only avoids the risks and complications derived from repeated laparotomy but also causes less tissue injury and consequently evokes a minor innate immune response. Because the combination of solid organ transplantation and laparoscopy is one of the medical fields that is still in evolution, we want to contribute to its progress by reporting this case. CASE DESCRIPTION AND TECHNIQUE A 43-year-old Caucasian male with hepatitis C virus– related cirrhosis (partial portal vein thrombosis, 2 episodes of ascitic decompensation, Model for End-Stage Liver Disease score of 17, and a Child-Pugh score of B9) underwent LT on June 16, 2012 with a bloodmatched donor. LT was performed according to the piggyback technique with an end-to-end portal anastomosis and a side-to-side arterial anastomosis. The bile duct was reconstructed with an end-to-end choledococholedocostomy without a T-tube. No intraabdominal drain was left.
Immunosuppressive treatment was initiated on postoperative day (POD) 1 with tacrolimus and mycophenolate mofetil according to the standard protocol at our center. On POD 3, the patient complained of abdominal pain associated with distension and an elevated abdominal pressure. Abdominal ultrasonography showed diffuse abdominal fluid. A diagnostic paracentesis confirmed generalized biliary peritonitis. The patient underwent emergency surgery with a totally laparoscopic approach.
Surgical Technique The patient was placed in the supine position, with the surgeon standing on the patient’s left side. A 5mm trocar was gently inserted through the previous subcostal incision, as previously described.2 Pneumoperitoneum was established at 12 mm Hg, and a 5mm 30 laparoscope was inserted. Some soft adhesions from the greater omentum to the anterior abdominal wall and the subcostal incision were released with the scope. Three additional 5-mm trocars were inserted; 1 of them also was inserted through the previous subcostal incision (Fig. 1). A thorough lavage of the abdominal cavity, including the pelvis and both subphrenic spaces, was performed. By gentle upward traction of the round ligament of the graft, the hepatic pedicle was exposed, carefully washed, and examined. A Nathanson retractor was bluntly inserted through the subcostal incision and fixed; this kept the hepatic pedicle exposed. The adhesions were still soft, and the structures, including the arterial and biliary elements, were easily identified. A defect on the left side of the biliary anastomosis was visualized (Fig. 2A,B). Once the leakage site was identified, the T-tube was inserted through 1 of the trocars. The anastomotic defect was slightly enlarged with scissors along the donor’s side, and both of the tube’s short branches were carefully inserted into the donor and recipient sides. The defect on the duct was sutured with a 6/0
Additional Supporting Information may be found in the online version of this article. Address reprint requests to Fernando Rotellar, Hepatopancreatobiliary Surgery and Liver Transplantation, Department of Surgery, University Clinic, Universidad de Navarra, Pamplona, 31008 Spain. Telephone: 0034 948 296797; FAX: 0034 948 296500; E-mail: [email protected] DOI 10.1002/lt.24068 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION. DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases C 2015 American Association for the Study of Liver Diseases. V
562 LETTER FROM THE FRONTLINE
LIVER TRANSPLANTATION, April 2015
A recent literature review including more than 14,000 LT procedures indicated an overall biliary leakage
incidence of 8.2%: 7.8% for deceased donor LT and 9.5% for living donor LT.1 Although several factors can influence the outcome of a biliary anastomosis, the reconstruction technique seems to be the most decisive. In the present case, we consider that a technical error in the performance of the anastomosis resulted in this complication. If a significant leak is identified, patients may benefit from the so-called conservative procedures, such as ERCP. Nevertheless, these procedures are not free from complications, some of which can be lifethreatening, such as duodenal perforations or severe pancreatitis. In select cases, a primary surgical revision may be indicated, particularly for large defects, severe peritonitis, early development of the leak (
LETTER FROM THE FRONTLINE
Pure Laparoscopic Management of Early Biliary Leakage After Liver Transplantation: Abdominal Lavage and T-Tube Placement Received November 29, 2014; accepted December 18, 2014.
TO THE EDITORS: Leakage is the second most frequent biliary complication (after anastomotic strictures) after liver transplantation (LT). Although the therapeutic approach is centerspecific and must be tailored to every patient’s circumstances, endoscopic retrograde cholangiography (ERCP) is usually the therapy of choice and has high success rates.1 Nevertheless, surgical revision may be indicated, particularly when large defects or severe peritonitis is observed. We present the case of an anastomotic biliary leakage with associated diffuse biliary peritonitis after LT that was successfully treated with a totally laparoscopic approach. It involved thorough abdominal lavage and leakage repair by T-tube placement. Laparoscopic surgery is a widely accepted approach in several surgical fields because it is advantageous in terms of postoperative recovery. In the postoperative course after LT, this minimally invasive approach not only avoids the risks and complications derived from repeated laparotomy but also causes less tissue injury and consequently evokes a minor innate immune response. Because the combination of solid organ transplantation and laparoscopy is one of the medical fields that is still in evolution, we want to contribute to its progress by reporting this case. CASE DESCRIPTION AND TECHNIQUE A 43-year-old Caucasian male with hepatitis C virus– related cirrhosis (partial portal vein thrombosis, 2 episodes of ascitic decompensation, Model for End-Stage Liver Disease score of 17, and a Child-Pugh score of B9) underwent LT on June 16, 2012 with a bloodmatched donor. LT was performed according to the piggyback technique with an end-to-end portal anastomosis and a side-to-side arterial anastomosis. The bile duct was reconstructed with an end-to-end choledococholedocostomy without a T-tube. No intraabdominal drain was left.
Immunosuppressive treatment was initiated on postoperative day (POD) 1 with tacrolimus and mycophenolate mofetil according to the standard protocol at our center. On POD 3, the patient complained of abdominal pain associated with distension and an elevated abdominal pressure. Abdominal ultrasonography showed diffuse abdominal fluid. A diagnostic paracentesis confirmed generalized biliary peritonitis. The patient underwent emergency surgery with a totally laparoscopic approach.
Surgical Technique The patient was placed in the supine position, with the surgeon standing on the patient’s left side. A 5mm trocar was gently inserted through the previous subcostal incision, as previously described.2 Pneumoperitoneum was established at 12 mm Hg, and a 5mm 30 laparoscope was inserted. Some soft adhesions from the greater omentum to the anterior abdominal wall and the subcostal incision were released with the scope. Three additional 5-mm trocars were inserted; 1 of them also was inserted through the previous subcostal incision (Fig. 1). A thorough lavage of the abdominal cavity, including the pelvis and both subphrenic spaces, was performed. By gentle upward traction of the round ligament of the graft, the hepatic pedicle was exposed, carefully washed, and examined. A Nathanson retractor was bluntly inserted through the subcostal incision and fixed; this kept the hepatic pedicle exposed. The adhesions were still soft, and the structures, including the arterial and biliary elements, were easily identified. A defect on the left side of the biliary anastomosis was visualized (Fig. 2A,B). Once the leakage site was identified, the T-tube was inserted through 1 of the trocars. The anastomotic defect was slightly enlarged with scissors along the donor’s side, and both of the tube’s short branches were carefully inserted into the donor and recipient sides. The defect on the duct was sutured with a 6/0
Additional Supporting Information may be found in the online version of this article. Address reprint requests to Fernando Rotellar, Hepatopancreatobiliary Surgery and Liver Transplantation, Department of Surgery, University Clinic, Universidad de Navarra, Pamplona, 31008 Spain. Telephone: 0034 948 296797; FAX: 0034 948 296500; E-mail: [email protected] DOI 10.1002/lt.24068 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION. DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases C 2015 American Association for the Study of Liver Diseases. V
562 LETTER FROM THE FRONTLINE
LIVER TRANSPLANTATION, April 2015
A recent literature review including more than 14,000 LT procedures indicated an overall biliary leakage
incidence of 8.2%: 7.8% for deceased donor LT and 9.5% for living donor LT.1 Although several factors can influence the outcome of a biliary anastomosis, the reconstruction technique seems to be the most decisive. In the present case, we consider that a technical error in the performance of the anastomosis resulted in this complication. If a significant leak is identified, patients may benefit from the so-called conservative procedures, such as ERCP. Nevertheless, these procedures are not free from complications, some of which can be lifethreatening, such as duodenal perforations or severe pancreatitis. In select cases, a primary surgical revision may be indicated, particularly for large defects, severe peritonitis, early development of the leak (
