Int J Gastrointest Interv 2022; 11(4): 150-155
Published online October 31, 2022 https://doi.org/10.18528/ijgii220041
Copyright © International Journal of Gastrointestinal Intervention.
1Teaching and Research Department, DAICIM Foundation, Buenos Aires, Argentina
2Surgery Division, B. Rivadavia Hospital, Buenos Aires, Argentina
3Department of Surgery, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
4Solid Organ Transplant Service, Hospital de Alta Complejidad en Red El Cruce Dr. Néstor Carlos Kirchner, Buenos Aires, Argentina
Correspondence to:*Surgery Division, B. Rivadavia Hospital, Las heras 2670, CABA 1425, Argentina.
E-mail address: email@example.com (E.J. Houghton).
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Gastrointestinal surgery is a vast field with many types of procedures, of which hepato-pancreato-biliary (HPB) operations are among the most frequently performed worldwide. Several complications of HPB surgery may occur. Most of these complications, such as wound infection, bleeding, abdominal wall eventrations, and intestinal obstruction, also occur with other procedures. This review analyzes surgical management-related complications associated with HPB surgery, including pancreatic fistula, bile leakage, biliary stenosis, and bile duct damage. Most of the complications of HPB surgery can be managed conservatively or with minimally invasive procedures. Nevertheless, surgical management still plays an important role.
Keywords: Bile ducts, Liver, Pancreas, Postoperative complications, Surgical procedures, operative
Gastrointestinal (GI) surgery is a vast field with many different procedures, among which hepato-pancreato-biliary (HPB) operations are among the most frequently performed worldwide. HPB surgery also includes relatively simple procedures, such as cholecystectomy, hepatectomy, and pancreatoduodenectomy. These procedures are usually performed by professional HPB surgeons because experienced surgeons have much lower complication rates and higher success rates.1,2 Therefore, the surgeon’s experience and the size of the hospital affect the incidence of complications and the likelihood of favorable oncological outcomes, as demonstrated by Papageorge et al.3 Therefore, the appropriate choice of a surgeon and hospital is the first step in treatment of HPB surgical complications, as prevention is better than cure. For this reason, these types of procedures should only be performed at high-capacity centers by HPB-trained surgeons who perform all complex HPB procedures.
Pancreatic surgery is particularly challenging. Several procedures have been described, such as tumor enucleation, total pancreatectomy, pancreaticoduodenectomy, distal pancreatectomy with or without spleen preservation, the Puestow procedure, and the Partington-Rochelle procedure. Pancreaticoduodenectomy is perhaps the most frequently performed pancreatic surgery, with relatively high morbidity and mortality rates that reflect the difficulty of this procedure for both patients and surgeons. Advances in perioperative management have reduced the mortality rate to less than 5%, but the morbidity rate remains high (30%–65%).4–10 Several complications, such as wound infection, intestinal obstruction, and abdominal wall hernia, also occur with other operations. However, complications of this type are not analyzed in this manuscript because they go beyond the scope of this review. Instead, this review focuses on the specific complications of HPB surgery. Pancreatic fistulas, which are potentially among the most serious complications, occur in 5% to 20% of cases depending on the series and may be associated with life-threatening complications such as intra-abdominal abscesses, bleeding, or sepsis.11–16 Another frequent complication is delayed gastric emptying (DGE), with an incidence of 7% to 37%. DGE is not deadly, but it prolongs the hospital stay and increases costs.11,17–20
Liver surgery typically ranges from small metastatic resection, with relatively few complications, to trisectionectomies or liver transplantation, with higher complexity and higher rates of complications. The history of liver surgery started with a left lateral hepatic lobectomy performed by Langenbuch in Germany in 1887.21 Since then, extensive experiences have been gathered, but liver surgery still has high rates of postoperative morbidity (4.09%–47.7%) and mortality (0.24%–9.7%).21–36 Frequent post-liver surgery complications include some that are in common with other procedures (e.g., fever, hemorrhage, pleural effusion, and subphrenic infection). The focus herein is specific liver surgery-related complications such as hemorrhage and bile leakage, the incidence of which ranges from 4% to 17%.21,37–40
The most common procedure performed worldwide in connection with biliary tract surgery is laparoscopic cholecystectomy (LC), followed by hepaticojejunostomy (HJ), which is commonly used as a reconstructive step for other liver, pancreatic, or biliary tract procedures. LC is the standard treatment for gallbladder stones. Although the rate of complications is low, one of them (bile duct injury [BDI]), is among the complications most feared by surgeons. Its incidence increased from 0.125% to 0.3% for open cholecystectomy to 0.4% to 0.6% for LC.41–49 This increase in the incidence of BDIs associated with LC was also accompanied by an increase in their complexity.48
The most common complications associated with HJ are bile leakage and narrowing. These HJ-related complications will not be analyzed herein because they are often managed by an interventional radiologist.
The purpose of this review is to describe the current evidence and surgical management of certain complications of the most frequent HPB surgical procedures.
A comprehensive computer-aided literature search on HPB surgery was performed from no initial date to July 2022 using MEDLINE and Embase. The following Medical Subject Heading terms were used in the searches: pancreatic surgery, pancreatoduodenectomy, total pancreatectomy, biliary tract surgical procedures, hepaticojejunostomy stricture, BDI, revision, choledocho-choledochostomy, choledocho-enterostomy, choledocho-duodenostomy, bilio-biliary anastomosis, biliary-enteric anastomosis, hemorrhage, liver surgery, bile leakage, hepatectomy, and complications. All human case reports or studies fully published in English were included; abstracts only were excluded.
Liver resection is widely performed for the treatment of various liver diseases, such as malignant tumors, benign tumors, calculi in the intrahepatic ducts, hydatid disease, and abscesses.21 Hepatectomy has relatively high rates of postoperative morbidity (4%–47%).25,31,35,36 Common post-hepatectomy complications include fever, hemorrhage, bile leakage, liver failure, pleural effusion, and subphrenic infection.21 In this section, we focus on hemorrhage and bile leakage.
Hemodynamically unstable and non-responsive patients should undergo operative management.61 In case of major hemorrhage, more aggressive procedures, including manual compression and hepatic packing, ligation of vessels in the transection surface, balloon tamponade, shunting procedures, or hepatic vascular isolation and exclusion, may be used.62,63 If there is evident injury on some branches of the remnant hepatic artery, selective ligation is advisable.64 If the bleeding comes from behind the liver, retro-hepatic caval or hepatic vein injury should be strongly suspected.65,66 Laparoscopy should be considered as the initial approach to minimize the invasiveness of surgical intervention and to tailor the procedure to the lesion.61
The incidence of bile leakage ranges from 4.0% to 17%.21 According to the International Study Group of Liver Surgery, bile leakage after hepatectomy is defined as drainage of fluid with a bilirubin level three times greater than the serum level on postoperative day 3 or the need for an intervention owing to bilious collection or biliary peritonitis.67 Postoperative bile leakage is associated with an increased risk of post-hepatectomy liver failure and mortality.40,68 Common causes of postoperative bile leakage are: (1) truncation of the distal bile duct in the residual liver (the most common cause); (2) leakage at the bile duct-intestinal anastomosis or an incomplete suture around the T-tube; and (3) injury to the bile duct from an inappropriate surgical technique.21
Intractable bile leakage is defined as bile leakage that does not improve after a drainage procedure. Bile leakage was classified by Nagano et al69 into four types: type A, minor leakage from a cut surface; type B, leakage caused by insufficient closure of the bile duct stump; type C, leakage from the injured bile duct wall at the exposed bile duct or hilar bile duct; and type D, leakage from the distal orifice of the isolated bile duct. Type D bile leakage is intractable and cannot be treated by simple drainage alone. Patients with type D bile leakage must undergo surgical procedures, such as liver resection or biliodigestive anastomosis.70
Several studies have described risk factors for bile leakage. Yoshioka et al71 reported three independent risk factors: (1) multiple hepatectomy, (2) traumatized liver surface ≥ 57.5 cm2; and (3) intraoperative bleeding ≥ 775 mL. In addition, Sadamori et al72 found that an operative time ≥ 300 minutes was an independent risk factor for bile leakage after hepatectomy.
After surgery, close postoperative monitoring is mandatory. Bile leakage may be evident from the presence of bile in the peritoneal drainage (the concentration of bilirubin in the bile will be higher than in serum). A drainage tube can remain if there is no sign of peritonitis; the bile leakage may resolve spontaneously within 2 months. However, if peritonitis develops, open surgery should be performed as soon as possible for thorough cleaning of the abdominal cavity and repair of the damaged bile duct. In general, nonoperative treatment is sufficient if the results of endoscopic retrograde cholangiopancreatography and computed tomography are negative for bile leakage, but an operative intervention may be needed if conservative therapy fails.21
Biliary leaks from HJ are usually a major complication. They occur in 0.4% to 8% of patients, depending on the type of procedure.73 Liver resection, biliary complications after liver transplantation requiring HJ, preoperative radiochemotherapy, and preoperative cholinesterase level were significantly associated with postoperative bile leaks according to Antolovic et al.74
Low-volume leaks can be managed conservatively by just waiting until the leak is depleted by itself. However, high-volume leaks could lead to several complications, such as biloma, choleperitoneum, and peritonitis.73–75 Bilomas are often treated by percutaneous placement of a catheter; while choleperitoneum requires relaparotomy or relaparoscopy to conduct lavage and restore the dehiscence of the anastomosis if the local conditions permit. If not, a catheter should be placed in the biliary duct and the reconstruction should be deferred for a subsequent procedure. The algorithm for bile leak management is shown in Fig. 1.
There are several types of bile duct damage. Cho et al76 established a standardized reporting system, known as the Strasberg classification, in 2018. Different grades require different types of treatment. Several mini-invasive procedures have been developed in recent years, making it possible to solve most of these injuries. Initially, percutaneous and endoscopic procedures were performed to temporize by treating fluid collection and cholangitis, and HJ was performed second. Recently, however, these procedures have become the definitive treatment for more complex BDI.
Percutaneous HJ, percutaneous endoscopic rendezvous with magnets for recanalization of biliary stenosis, and radiofrequency ablation in canalicular stenosis are a few examples.77–80 The current algorithm for the management of BDI is shown in Fig. 2.
For biliary stenosis, the preferred treatment is balloon dilatation, with a clinical success rate of approximately 65%.81 In case of failure, the next step is continuous dilatation by endoscopy or percutaneously; Costamagna et al82 described performing this procedure endoscopically, with a clinical success rate of 80%.83 Continuous expansion applied by biodegradable bile stents or full-covered metal stents can achieve similar results.84,85 If all these mini-invasive treatments fail, the last option is to perform repeated HJ. This is a complex operation that must be performed at high-volume centers by experienced HPB surgeons in order to achieve acceptable rates of morbidity and mortality.86
For more complex BDIs without possible minimally invasive treatment, HJ is the preferred option. The clinical success rate of HJ is between 85% and 95%.87,88 In worse cases, liver resection or transplantation may be possible.89
There is some disagreement in the literature about the optimal time window for performing surgical HJ. Ismael et al89 compared early surgical restorations within 30 days to late restorations. They found a higher mortality rate in the early group, and Booij et al90 demonstrated a higher rate of HJ stenosis in early repair. Conversely, a recent E-AHPBA multicenter study did not show that the timing of biliary reconstruction had an impact on serious postoperative complications, the need for reintervention, or liver-related death. They concluded that individualized treatment after BDI is still advisable.91
The management of complications after pancreatic resection has shifted from an operative to a conservative approach, thanks to the establishment of multidisciplinary teams with high degrees of expertise. The International Study Group for Pancreatic Surgery (ISGPS) established standardized definitions and clinical grading systems for the most common complications, including pancreatic fistula, postpancreatectomy hemorrhage, and DGE.92
Postoperative pancreatic fistula (POPF) is the most common complication after pancreatic resection and it contributes significantly to mortality after pancreatic resections.93 Numerous articles showed that fistula risk encompasses endogenous, perioperative, and intraoperative factors, including age, sex, body mass index, diabetes mellitus, cardiovascular comorbidities, disease pathology, neoadjuvant therapy, use of prophylactic somatostatin analogs, pancreatic duct caliber, pancreatic remnant texture, anastomotic technique, the use of a transanastomotic stent, intraoperative blood loss, operative time, and routine drain placement.94
POPF management is usually nonsurgical, but some cases require revision surgery and are classified as International Study Group of Pancreatic Fistula grade C. The indications for relaparotomy are not uniform across different series and depend on the expertise and patients’ conditions. In general, an operative intervention must be considered in cases of clinical deterioration despite maximal supporting care, infected intra-abdominal collections inaccessible to percutaneous or endoscopic drainage, suspected peritonitis due to visceral perforation, and drainage limb necrosis.92
Pancreatic stump management in relaparotomy encompasses multiple surgical options, including debridement and wide drainage of the peripancreatic region, attempted repair of the site of leakage, construction of a new pancreatic-enteric anastomosis, resection of the pancreatic-enteric anastomosis with remnant closure, and completion pancreatectomy. The choice is often dictated by the intraoperative findings and the patient’s clinical status. Regardless of the surgical approach, it has been shown that subsequent operations were required in approximately 50% of patients with re-operations. The majority of these were necessary in patients with septic complications requiring open abdominal lavage with secondary abdominal wall closure.95
Postpancreatectomy hemorrhage is one of the most feared complications after pancreatectomy due to its association with high mortality; the reported rates of this complication are between 3% and 10% in most series.92 In accordance with the ISGPS definition, postpancreatectomy hemorrhage is graded based on onset, location, and severity. Whereas early postpancreatectomy hemorrhage is often due to inadequate hemostasis or an underlying coagulopathy, late postpancreatectomy hemorrhage is often the result of a multifactorial pathophysiological mechanism, including an association with other pancreatectomy specific complications, such as POPF.96 Severe postpancreatectomy hemorrhage requires fast and effective management. The management of early postpancreatectomy hemorrhage is mostly through relaparotomy.97 POPF is associated with late postpancreatectomy hemorrhage, as the leakage of enzyme-rich fluid into the abdomen might cause vessel erosion, which can result in the formation of a pseudoaneurysm. Pseudoaneurysms are known to rupture and consequently can cause late hemorrhage.51 Identifying the source of the hemorrhage during relaparotomy can be challenging, especially in a patient with severe POPF. According to the current literature, hemorrhage after pancreatectomy is relatively rare, with an incidence of 5%, but a mortality rate of 21%, making it the most lethal pancreatectomy-specific complication, and it is important to pay attention to its appearance to ensure a rapid resolution.96
DGE is a potentially serious event that may lead to patient discomfort, further interventions, prolonged hospitalization, higher readmission rates, and increased hospital costs. The diagnosis of DGE remains nebulous, with no test that clearly defines the physiologic function of the GI tract. The reported DGE incidence ranges from 13.8% to more than 40%.92 In addition, DGE needs nonoperative management.
In conclusion, most HPB surgery complications can be managed conservatively or by minimally invasive procedures. Nevertheless, surgical management still plays a key role, and knowing how and when to decide to shift from a conservative or minimally invasive approach to a surgical approach is as important as the surgical approach itself.
No potential conflict of interest relevant to this article was reported.
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