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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1143_Библиотеки_им_академика_М_И_Перельмана
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Fig. 26.1 Liver abscess at
the surface of segments 2
and 3 resection
Fig. 26.2 Percutaneously
drained liver abscess
M.A. Cuesta
of fi xation to the hilar plate, RFA was performed, but also used to treat the lesions
located in segments 4a and 4b and 8. Moreover, segments 2 and 3 were resected.
Postoperative Course: Identifi cation of the Complication
Operation had no complications and the patient could be discharged at sixth
postoperative day. After 3 months, he was again admitted to the hospital because of
high fever and upper abdominal pain. On the CT scan, an abscess was found at the
level of the resection being drained percutaneously (Figs. 26.1 and 26.2 ). New
admissions followed with new abscesses, not only in the resection area but also in
rest of the liver. Progressive hepatic failure developed with hypoalbuminemia,
altered coagulation, and edema. Finally, the patient died.
26 Case on Jaundice and Hepatic Failure After Major Hepatic Resection
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Fig. 26.3 Liver cyst
Fig. 26.4 Liver cyst treated
by alcohol injection
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Second Patient
Diagnosis and Indication for Surgery
A 65-year-old female patient already known having a huge liver cyst and being
conservatively treated was admitted from another hospital with mechanical complaints of the upper digestive tract, as caused by a cyst of 25 cm found by CT scan
26.3 ). An open cholecystectomy had been performed 7 years before. It was
(Fig.
decided to treat the cyst by alcohol injection, and the treatment was considered successful (Fig. 26.4 ). Patient was readmitted 3 weeks later with a distended abdomen
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Fig. 26.5 Liver cyst showing
clots inside and compression
of the vena cava
M.A. Cuesta
and two edematous legs and decreased hemoglobin rate. On CT scan and duplex
study, the cyst appeared unchanged in size, but showing clots inside as sign of bleeding. An important compression of the retrohepatic vena cava was found to produce
an inferior vena cava syndrome (Fig. 26.5 ). Moreover, the patient had a low albumin
and coagulation disorders as caused by a liver insuffi ciency. After correction of the
coagulation disorders by vitamin K and plasma factors, a decision was taken to perform a partial cystectomy of the cyst in order to decrease the pressure on the vena
cava, to decompress the liver parenchyma, and to diminish the mechanical
complaints.
Operation
A subcostal incision was performed, and a partial cystectomy performed after
drainage by puncture. Hereafter a brown fl uid with some necrosis was drained,
a possible effect of alcohol therapy. Inspection of the cyst was done, vena cava inferior and hilar elements appeared visible and not covered by cyst wall tissue. After
deroofi ng, the wall of the cyst was sent to pathology for study. Omentum plasty was
performed in the cyst. Patient recovered very quickly, edema disappeared, and she
was discharged at the ninth postoperative day.
Discussion
Liver insuffi ciency is characterized by a defi cit in factors produced by the liver such
as albumin, coagulation factors, and glucose metabolism or eliminated by the liver
like ammonia. Decrease of these functions determine the clinic of the patients such
26 Case on Jaundice and Hepatic Failure After Major Hepatic Resection
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145
as progressive jaundice, ascites and peripheral edema, coagulation problems and
encephalopathy (excessive nitrogen load and ammonia) [ 1 ].
Reference
1. Rahbari NN, Garden OJ, Padbury R, et al. Posthepatectomy liver failure: a defi nition and grad-
ing by the international study group of liver surgery (ISGLS). Surgery. 2011;149:713–24.
Chapter 27
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Case on Biliary Leakage and Abscess
After Liver Resection
Suzanne S. Gisbertz
Keywords Biliary leakage • Abscess • Liver resection • Hemicolectomy •
Adenocarcinoma
Diagnosis and Indication for Surgery
A 66-year-old lady underwent a right hemicolectomy in 2008 because of an adenocarcinoma stage T3N0M0.
One year later, three liver metastases were found on the CT scan: in segments
5, 6, and 4b (Fig. 27.1 ). She was treated with neoadjuvant chemotherapy in the form
of Xeloda ® , in three cycles. A very important response of the metastases was
observed on the CT scan. Six weeks later, she underwent a liver resection of the
above segments 5, 6, and 4b.
Postoperative Course: Identifi cation and Treatment
of the Complication
Her postoperative period was complicated by a high-production bile leakage along
the drain (Fig. 27.2 ). The subhepatic collection was treated by a percutaneous drain
and in order to decrease the fl ow, an ERCP and a papillotomy with stent placement
were performed (Fig.
and fi nally the drains could be retired. One month later, a deep wound abscess was
S. S. Gisbertz , M.D.
Department of Surgery ,
Academic Medical Centre ,
Amsterdam , The Netherlands
e-mail: s.gisbertz@antoniusziekenhuis.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_27,
© Springer International Publishing Switzerland 2014
27.3 and Illustration 27.1 ). Leakage decreased signifi cantly
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Fig. 27.1 Liver metastases
Fig. 27.2 Leakage of bile
S.S. Gisbertz
drained. Four months after operation, she was admitted again to the hospital because
of abdominal pain and high fever. On the CT scan, an abscess was found at the
place of the liver resection and it was drained percutaneously (Fig. 27.4 ). Moreover,
27 Case on Biliary Leakage and Abscess After Liver Resection
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Fig. 27.3 Percutaneously
drainage and endoprosthesis
Fig. 27.4 Recurrent liver
abscess
149
thinking that the biliary stent was occluded, this was removed by a new ERCP. In the
period of 3 months after, the patient was admitted twice because of recurrence of
the abscess, being subsequently drained. Ten months postoperatively, a recurrence
of two metastases was seen on the control CT scan (Fig. 27.5 ). On the Oncology
Multidisciplinary Commission, the second-line chemotherapy, Irinotecan ® , was
proposed. During the two cycles, she reacted with fever, and on the CT scan again a
small abscess was diagnosed in the liver, including pulmonary metastases. In spite
of drainage of the abscess and chemotherapy, the pulmonary metastases showed to
be progressive. The patient decided to stop treatment.
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Fig. 27.5 Recurrent
metastases
S.S. Gisbertz
Percutaneous drain
Illustration 27.1 After diagnosis of bile leakage after liver resection, the collection has been
drained percutaneously and to decrease the bile pressure a sphincterotomy be performed with
placement of a stent
Stent
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151
Discussion
Biliary complications are the most common and potentially serious complications
and can appear postoperatively as fi stulas and/or bile collections, as a diffuse bile
peritonitis, or as a sepsis due to the existence of segments with poor bile drainage [ 1 ].
Biliary fi stulas were recently classifi ed in three grades [ 2 ]: grade A biliary fi stula
has little or no clinical impact on the patient; the fi stula is controlled by drainage,
the drainage volume decreases daily, and bile drainage lasts less than 1 week. Grade
B biliary fi stula causes a change in the patient’s clinical situation and treatment,
requiring additional radiological or endoscopic approaches, the hospital stay is
lengthened, or it is a grade A fi stula with more than 1 week’s hospital stay. Grade C
biliary fi stula requires laparotomy for treatment, and occasionally a clinical situation of sepsis or multisystemic failure occurs. Hospital stay is very prolonged, and
patients may have secondary complications (e.g., wall abscesses).
Prevention is implemented by performing a systematic intraoperative cholangiography (IOC) in the case of hemihepatectomies or extended LRs. When a hepatectomy is fi nished, the bile duct must also be explored by IOC or by injecting serum
through the cystic duct to identify minor biliary leaks on the liver surface. Segments
that have become ischemic during the liver resection should be excised.
Treatment. Injury to a principal hepatic duct must be treated with an HJ reconstruction. If a segment is left poorly drained, it must be excised to avoid secondary
infectious complications or the biliary radicle sutured if it is of little importance.
If it appears as a biliary fi stula through the drain, which does not close conservatively, we must identify the origin by performing a cholangiography through the
drain or an ERCP, which allows a papillotomy to be performed, and also insert a
nasobiliary drain or an endoscopic plastic prosthesis. If endoscopic treatment fails,
the next step is surgical treatment. If it appears as an infected perihepatic collection,
detected by CT, a radiological drain must be inserted and if a high volume of drainage is maintained it should be treated as a biliary fi stula.
Infected collections. Favoring factors include liver resections with biliodigestive
anastomoses, patients with previous chemotherapy, the application of intraoperative
radiofrequency, and immunodepressed patients [ 3 ].
In the presence of fever, leukocytosis, and increased CRP, we must indicate an
emergency abdominal CT. If there are clinical data of sepsis or air inside the collection, the collection must be drained radiologically as an emergency procedure. On
rare occasions these collections are not resolved with radiological treatment and
surgical treatment is necessary. In selected cases with less than 38 °C fever, no leukocytosis, and no hemodynamic repercussion, antibiotic treatment can be started
under clinical, analytical, and serial-CT guidance [ 1 ] .
References
1. Parrilla Paricio P, Robles Campos R, Sanchez BF. Prevention and treatment of major complica-
tions of liver surgery. In: Cuesta MA, Bonjer HJ, editors. Treatment of complications after
digestive surgery, chapter 11. London: Springer; 2013.
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2. Koch M, Garden OJ, Padbury R, et al. Bile leakage after hepatobiliary and pancreatic surgery:
a defi nition and grading of severity by the International Study Group of Liver Surgery. Surgery.
2011;149:680–8.
3. Zimmitti G, Roses RE, Andreou A, et al. Greater complexity of liver surgery is not associated
with an increased incidence of liver-related complications except for bile leak: an experience
with 2,628 consecutive resections. J Gastrointest Surg. 2013;17:57–64.
S.S. Gisbertz
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