Jennifer L. Swank, PharmD, BCOP

Covered stents are particularly helpful for gastroduodenal artery stump blowouts (in which coil embolization might not be technically possible) administering medications 6th edition order cheap tolterodine online, distal splenic artery pseudoaneurysms (where embolization has a higher risk of splenic infarction) treatment yeast infection nipples breastfeeding tolterodine 1 mg purchase on line, common and proper hepatic artery pseudoaneurysms (to preserve arterial flow to the liver) medications during labor generic tolterodine 1 mg amex, and superior mesenteric artery pseudoaneurysms (to preserve flow to bowel) treatment jalapeno skin burn buy genuine tolterodine on line. In the landmark paper by Foster and Berman from 1977 treatment gastritis buy tolterodine online, overall mortality in a multicenter analysis of 621 hepatic resections was 13%, and even greater (20%) in patients undergoing major hepatic re section. Mortality for hepatic resections has improved significantly since that time with and currently ranges from 0% to 3% at high-volume centers (Table 27. Unfortunately, other outcomes have not improved in parallel with mortality such that overall morbidity is still reported in the range of 14% to 45% (see Chapter 103). Since the time of Foster and Berman, the field of hepatobiliary surgery has benefited from a better understanding of liver anatomy, advances in cross-sectional imaging technology, expanded use of parenchymal-sparing approaches, improved anesthetic techniques, and better patient selection. These improvements are reflected in a recent multi-institutional study of 2056 patients undergoing hepatic resection between 1990 and 2011 (Hyder et al, 2013). Of note, whereas bleeding accounts for a minor percentage of overall morbidity in the current series, 30 years ago it was the primary cause of overall mortality following hepatectomy (Foster & Berman, 1977). A list of common complications reported after major hepatic resections in several large series since 2000 is presented in Table 27. Percutaneous Biliary Drainage See "Interventional Management of Bilomas and Bile Leaks," and "Interventional Management of Biliary Strictures," later. Angiography, Embolization, and Covered Stent Placement (See Chapters 21 and 30) Hemorrhage is seen in less than 10% of patients after pancreatectomy but is associated with high mortality (Puppala et al, 2011). Major bleeding is seen on average 19 days after surgery and is usually preceded by a smaller sentinel bleed (Otah et al, 2002). Bleeding can be due to vessel injury during surgery or due to pancreatic fluid eroding the vessel wall. Hemodynamically unstable patients should proceed directly to catheter angiography and intervention, or to the operating room. Pseudoaneurysms and arterial extravasation after pancreatic surgery occur in the gastroduodenal artery most commonly, followed by the hepatic artery, superior mesenteric artery, and splenic artery (Tien et al, 2008) (see Chapter 124). Selective coil embolization across the pseudoaneurysm is successful in approximately 85% of patients (Tsai et al, 2007). In an otherwise normal liver, the hepatic arteries on the right or left side can be safely coil embolized, because the embolized lobe of the liver will be supplied by the portal vein and intrahepatic arterial collaterals (Nicholson et al, 1999). This may range from a transient decline in liver function requiring no specific intervention (grade A) or progress to fulminant liver and multisystem organ failure (grade C) (Kauffmann & Fong, 2014). Risk factors include large-volume blood loss, prolonged operative time, and major resection of greater than 50% of liver volume (Kauffmann & Fong, 2014; Nonami et al, 1999). Unfortunately, patients who progress to this point and fail conservative management ultimately require liver transplantation to survive (Kauffmann & Fong, 2014). Bile Leak Bile leakage is a common complication following hepatic resections, with an incidence ranging from 3. It occurs at the cut surface of the liver remnant, from the closed stumps of hepatic ducts, and from injury to the extrahepatic bile duct. When present, bile leaks may prolong hospital stay, delay drain removal, or even require return to the operating room in severe cases. This may be determined from the intraabdominal drains placed at the time of surgery or through invasive interventions. Grade A bile leaks are transient with little to no clinical impact, grade B leaks require additional diagnostics and potentially percutaneous drainage, and grade C leaks require relaparotomy for bile peritonitis. A prospective, multiinstitutional validation study of 949 hepatic resection demonstrated a 7. Interestingly, use of intraoperative drains was identified as an independent predictor of bile leak but did not affect the chances of requiring an intervention. Moreover, 100% and 91% of grade A and B leaks, respectively, were detected in cases with intraoperative drains. It should be noted that bile leakage rates after complex resections that also involve biliary reconstruction, for example, hilar cholangiocarcinoma, are higher than after standard resections and often involve more complex management (see Chapters 51, 52, and 103C). It is also possible, albeit rare, for delayed injury to arterial structures to manifest postoperatively and for vascular ties or clips to detach from short hepatic vein stumps along the vena cava. The in-hospital mortality for grades A, B, and C was 0%, 17%, and 50%, respectively. Multivariate analysis performed by Jarnagin and colleagues (2002) identified the number of hepatic segments resected and operative blood loss as factors predictive of overall morbidity and mortality. Moreover, blood loss, transfusion, and extent of resection have been correlated specifically with increased rates of postoperative liver failure and bile leaks (Brooke-Smith et al, 2015; Kauffmann & Fong, 2014; Nonami et al, 1999). In recognition of these associations, there has been great interest in developing techniques aimed at reducing blood loss and transfusions and limiting resections. One example of this is the more widespread use of parenchymal-sparing approaches, which several studies have reported to have less perioperative morbidity without compromising oncologic results (de Haas et al, 2008; Gold et al, 2008) (see Chapter 108). Techniques and devices intended to improve intraoperative efficiency and hemostasis during parenchymal transection have been studied extensively to determine their effect, if any, on postoperative complications (Pamecha et al, 2009; Poon, 2007). Among the numerous techniques studied in randomized trials-crush-clamping, stapling systems, vessel sealing systems. This may be due to the fact that these trials are usually performed at high-volume centers where the skill among experienced liver surgeons could make it difficult to demonstrate small differences among techniques (Arita et al, 2005; Ikeda et al, 2009; Palavecino et al, 2010; Patrlj et al, 2010). In a recent Cochrane Review analyzing seven randomized controlled trials that compared methods for parenchymal division, the authors concluded that the crush-clamp technique was the procedure of choice (Pamecha et al, 2009). Their decision was based on the fact that parenchymal transection devices were slower and significantly more expensive, while offering no advantages in time reduction or reduced blood loss compared with crush-clamping (see Chapter 103). Postoperative bilomas, hematomas, and abscesses can be detected with these modalities. The typical appearance of biloma on imaging is that of an encapsulated fluid collection adjacent to the liver resection plane. Rim enhancement of a fluid collection suggests infection, but this is not a specific finding. In some cases, aspiration may be required to distinguish infected and noninfected collections. A postoperative biloma, hematoma, or seroma might initially be sterile but can progress to become an abscess. The 3D images can be helpful for more precise anatomic localization (see Chapter 17). Interventional Radiology Procedures Posthepatectomy Intrahepatic Abscess Drainage Small pyogenic liver abscesses can be successfully treated with antibiotics alone. Large (>3 cm) unilocular abscesses can be treated by percutaneous drainage and antibiotics. Large multiloculated abscesses have a lower success rate with percutaneous drainage, and might require surgery (Hope et al, 2008) (see Chapter 12). When biliary obstruction is present, relief of the obstructed biliary tree is mandatory for successful abscess treatment. Abscesses located near the dome of the liver may be technically more difficult to drain without transgressing the pleura. Interventional Management of Bilomas and Bile Leaks After liver tumor resection, bile can leak from a bile duct injury, biliary-enteric anastomosis, or the cut surface of the liver. Bile leakage can cause bile peritonitis, as well as bilious fluid collections that can become infected. When an infected biloma is drained, the fluid can initially appear purulent, and then it may turn bilious if there is a continued bile leak after the infection clears. Ideally, the drain should be placed near the bile leak to provide optimal drainage (see Chapter 42). A, Postoperative computed tomography showed a fluid collection at the liver resection margin (asterisk), which was treated with percutaneous catheter placement. B, Contrast injection into the cavity under fluoroscopy showed a small biloma cavity (asterisk) communicating with the common hepatic bile duct (arrow), with contrast then flowing into the duodenum (arrowhead). Endoscopic retrograde cholangiopancreatography was performed, and a plastic stent was placed into the common bile duct to decrease the output of the fistula. Complete transection of a bile duct at the hilum typically requires surgical repair (see Chapter 42). Percutaneous biliary drainage is the preferred treatment for high bile duct injuries (at or above the bifurcation), and biliaryenteric anastomotic leaks, both of which are difficult to access endoscopically. Percutaneous biliary drainage leads to resolution of 88% to 100% of postoperative bile leaks, after an average of 1 to 3 months of drainage (Cozzi et al, 2006; Ernst et al, 1999). Intractable bile leaks can be managed with surgery, portal vein embolization (Hai et al, 2012), or bile duct embolization with N-butyl cyanoacrylate glue (Vu et al, 2006). Interventional Management of Biliary Strictures Postoperative biliary strictures can occur after hepatectomy (see Chapter 103), cholecystectomy (see Chapters 38 and 42), choledochojejunostomy, liver transplant (see Chapter 120), and other procedures. These strictures can be caused by direct biliary injury from surgery, ischemia, or recurrent tumor. Benign and malignant strictures can be difficult to distinguish on imaging, and biopsy may be required. High bile duct obstruction and biliary-enteric anastomotic strictures, both of which are difficult to access endoscopically, can be treated with percutaneous biliary drain or metal stent placement (see Chapter 30). Metal stents are typically only used for malignant obstruction, as they have a limited patency rate-30 months on average when used for benign disease (Tesdal et al, 2005). If the biliary stricture cannot be crossed percutaneously, an external biliary drain can be placed. If the biliary stricture can be crossed, an internal/external biliary drain is placed, which has side holes both above and below the obstruction. An internal/external biliary drain can be capped if there is no leak, infection, or significant blood in the bile, and should be flushed daily with 10 mL normal saline to maintain patency. Biliary drains are typically exchanged every 3 months to prevent clogging but are exchanged more frequently if cholangioplasty or other interventions are planned. An over-the-wire cholangiogram can be performed through a sheath that does not cross the bile duct injury, to evaluate for persistent leak or stenosis. If the bile duct injury has resolved on the cholangiogram, then an external biliary drain can be placed to maintain access to the bile ducts. If the patient passes the capping trial (no fever, no significant leakage around the tube, no rise in bilirubin), then the drain can be safely removed. Nonsurgical management of benign biliary strictures are typically managed with endoscopic placement of a plastic biliary stent, or percutaneous internal/external biliary drainage. Cholangioplasty can be performed using a high-pressure balloon during biliary drain placement or exchange. High pressures and prolonged cholangioplasty (as long as 15 minutes) are typically required to overcome the dense fibrous tissue around biliary strictures. An 8-mm balloon can be used for intrahepatic strictures and a 10- to 12-mm balloon for common duct strictures. Cholangioplasty can be repeated at 2- to 14-day intervals (Cantwell et al, 2008; Zajko et al, 1995). For benign biliary strictures, cholangioplasty and internal/external biliary drainage have a long-term (25 years) primary success rate of 59% and a secondary success rate of 80% (Cantwell et al, 2008). Failure of these approaches in otherwise healthy patients should prompt consideration of operative management (see Chapter 42). Malignant biliary obstruction can be relieved with a biliary drainage catheter, to treat cholangitis, pruritus, or to lower bilirubin for chemotherapy. A metal biliary stent can be placed (percutaneously or endoscopically) for palliation of unresectable symptomatic biliary obstruction in patients with limited life expectancy. Metal biliary stents placed for malignant obstruction remain patent for an average of 11 months (Dahlstrand et al, 2009). Bleeding Complications See "Angiography, Embolization, and Covered Stent Placement," earlier. Chapter 27 Postoperative complications requiring intervention: diagnosis and management 474. Adham M, et al: Central pancreatectomy: single-center experience of 50 cases, Arch Surg 143:175­180, discussion 180­181, 2008. Arita J, et al: Randomized clinical trial of the effect of a saline-linked radiofrequency coagulator on blood loss during hepatic resection, Br J Surg 92(8):954­959, 2005. Bassi C, et al: Management of complications after pancreaticoduodenectomy in a high volume centre: results on 150 consecutive patients, Dig Surg 18(6):453­457, discussion 458, 2001. Braga M, et al: A prognostic score to predict major complications after pancreaticoduodenectomy, Ann Surg 254(5):702­707, discussion 707­708, 2011. Büchler M, et al: Role of octreotide in the prevention of postoperative complications following pancreatic resection, Am J Surg 163(1):125­ 130, discussion 130­131, 1992. Cope C, et al: Percutaneous management of chronic pancreatic duct strictures and external fistulas with long-term results, J Vasc Interv Radiol 12(1):104­110, 2001. Correa-Gallego C, et al: Contemporary experience with postpancreatectomy hemorrhage: results of 1,122 patients resected between 2006 and 2011, J Am Coll Surg 215(5):616­621, 2012. Cozzi G, et al: Percutaneous transhepatic biliary drainage in the management of postsurgical biliary leaks in patients with nondilated intrahepatic bile ducts, Cardiovasc Interv Radiol 29(3):380­388, 2006. Crippa S, et al: Middle pancreatectomy: indications, short- and longterm operative outcomes, Ann Surg 246:69­76, 2007. Darwin P, et al: Jackson Pratt drain fluid-to-serum bilirubin concentration ratio for the diagnosis of bile leaks, Gastrointest Endosc 71(1):99­ 104, 2010. Dindo D, et al: Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey, Ann Surg 240(2):205­213, 2004. Epelboym I, et al: Quality of life in patients after total pancreatectomy is comparable with quality of life in patients who undergo a partial pancreatic resection, J Surg Res 187:189­196, 2014. Erdogan D, et al: Incidence and management of bile leakage after partial liver resection, Dig Surg 25(1):60­66, 2008.

Minimally invasive approaches have both revolutionized the treatment of patients with gallbladder disease for the better and changed the profile of cholecystectomy medications 2 buy tolterodine 1 mg without a prescription. On the whole treatment 5th disease tolterodine 1 mg purchase without a prescription, cholecystectomy patients now tend to be younger and healthier medications with pseudoephedrine purchase cheap tolterodine, whereas patients undergoing open cholecystectomy tend to be older and less well medications gerd discount tolterodine 1 mg overnight delivery, and the open operation is often performed in higher-risk alternative medicine cheap tolterodine 4 mg buy, complicated scenarios (Khan et al, 2007; Nilsson et al, 2005; Shea et al, 1998) (see Chapter 35). Laparoscopic cholecystectomy itself continues to advance; widespread prevalence and familiarity with this procedure has led surgeons to experiment with more advanced minimally invasive approaches, such as single-incision and robotic cholecystectomy (Himpens et al, 1998; Navarra et al, 1997). Indications are also broadening, as evidenced by the dramatic increase in the number of procedures performed for acalculous disease (Johanning & Gruenberg, 1998). Gallstones are present in approximately 15% of the population in the United States and Europe (Sakorafas et al, 2007). In the majority of symptomatic patients, gallstones provoke epigastric or right upper quadrant pain that often occurs after fatty meals (see Chapter 13). This pattern of symptoms is most commonly treated with cholecystectomy, which is successful in eliminating pain in 70% to 90% of these patients (Berger et al, 2003; Fenster et al, 1995, Gui et al, 1998). Impacted gallstones that obstruct bile outflow through the cystic duct result in acute cholecystitis. This typically manifests with fevers, right upper quadrant pain, leukocytosis, nausea, and vomiting. Laparoscopic cholecystectomy is also the preferred approach in this setting, although conversion to an open procedure occurs in 10% to 20% of cases (Gutt et al, 2013; Ingraham et al, 2010). Carcinoma of the gallbladder is an uncommon problem, with approximately 9850 new cases diagnosed in the United States each year (Siegel et al, 2012) (see Chapter 49). Unfortunately, gallbladder cancer is associated with an extremely poor prognosis with 5 year survival rates of 5% to 10% and an overall median survival of 3 to 6 months from diagnosis (Hueman et al, 2009). Because of both the poor prognosis of gallbladder cancer and the difficulty delineating benign from malignant gallbladder polyps, cholecystectomy is often used in the treatment of gallbladder polyps. Several more contentious indications for cholecystectomy fall under the heading of functional biliary disorders. Patients with persistent episodes of prolonged right upper quadrant abdominal pain without a defined etiology. Unfortunately, although criteria for the diagnosis of these disorders exist (Behar et al, 2006; Geenen et al, 1989), they are not always used. Various studies suggest that patients with motility disorders of the gallbladder may benefit from cholecystectomy, with reported rates of symptom resolution of 66% to 100% (Chen et al, 2001; Freeman et al, 1975; Goussous et al, 2014; Westlake et al, 1990). These indications and others warranting cholecystectomy have been summarized in the Society of American Gastrointestinal and Endoscopic Surgeons guidelines for the applications of laparoscopic biliary surgery (Overby et al, 2010). Perhaps not surprisingly, low rates of morbidity and mortality with minimally invasive approaches have extended the application of laparoscopic cholecystectomy to patients who have no clear indication for the procedure. This appears to be one drawback of the technologic advances that have decreased morbidity. In 1995, Jatzko and colleagues (1995) published a multivariate comparison of postcholecystectomy complications demonstrating higher morbidity (7. Soon thereafter, a meta-analysis comparing 98 studies of laparoscopic cholecystectomy with 28 studies of open cholecystectomy measured the rate of mortality for laparoscopic cholecystectomy to be 0. Such national database studies have also been used to identify risk factors for complications following cholecystectomy. Murphy and colleagues (2010) showed on multivariate analysis that risk factors for complications following laparoscopic cholecystectomy included advanced age, male gender, and comorbidities. In our view, these diagnoses can be divided into three groups: technical problems apparent in the intraoperative or perioperative setting (immediate technical problems), technical problems that often take months to years to manifest (delayed technical problems), and functional problems that are often unrelated to the operation and are sometimes present preoperatively (functional problems). Notably, overlooked extrabiliary disorders may be the most common cause of postcholecystectomy pain (Jaunoo et al, 2010). The majority of bile leaks following laparoscopic cholecystectomy are from two sources: the cystic duct stump and aberrant branches of hepatic ducts, including ducts of Luschka (Barkun et al, 1997; Bergman et al, 1996; Kim & Kim 2014; Rustagi & Aslanian 2014; Ryan et al, 1998; Tewani et al, 2013; Way et al, 2003). Abdominal pain, fever, ascites, and jaundice are the most common presentations (Agarwal et al, 2006; Barkun et al, 1997; Bjorkman et al, 1995; Ferriman, 2000; Kim et al, 2010; Kim & Kim, 2014; Pawa & Al-Kawas, 2009). Bilious drainage from operative drains or percutaneous drains placed postoperatively typically confirms the diagnosis. Endoscopic procedures aimed at eliminating the pressure gradient across the sphincter of Oddi to create preferential flow of bile into the duodenum are commonly used in this setting, and although multiple studies have reported high success rates associated with endoscopic sphincterotomy in the management of minor bile leaks, ranging from 80% to 100% (Katsinelos et al, 2008; Mavrogiannis et al, 2006; Ryan et al, 1998), there is no clear proof that these procedures are superior to drainage alone. It is clear, however, that surgery is rarely required to treat most bile leaks and is now largely reserved for the most feared complication of cholecystectomy-major bile duct injury. Gallstones and Gallbladder Chapter 38 Postcholecystectomy problems 635 et al, 1993; Harboe & Bardram, 2011; Nuzzo et al, 2005; Tantia et al, 2008; Vecchio et al, 1998; Waage & Nilsson, 2006). Universal adoption of the laparoscopic approach now allows the learning curve to be more easily surmounted during surgical training. Indeed, the most recent data suggest that the rate of bile duct injury may be decreasing with more laparoscopic experience (Grbas et al, 2013) and that laparoscopy is no longer associated with an increased risk of bile duct injury (Fullum et al, 2013). Regardless, a significant fraction of injuries are purely technical and unrelated to experience (Archer et al, 2001). The most common reason for major bile duct injury is failure to identify the anatomy of the triangle of Calot (Strasberg et al, 1995). Bile duct injury has been minimized by application of the "critical view of safety" in laparoscopic cholecystectomy (Strasberg et al, 1995; Strasberg & Brunt, 2010). The critical view requires clearance of fat and fibrous tissue from the triangle of Calot, separation of the gallbladder from the lower third of the cystic plate, and that two and only two structures be seen entering the gallbladder. The advantage of applying the critical view is that the surgeon cannot proceed to the division of structures if the anatomy is misidentified. However, when and whether the critical view has been met can be a matter of contention. Bile duct injuries in which biliary-enteric continuity persists can be managed endoscopically, but the mainstay of treatment for major bile duct injuries remains surgery (see Chapter 42). Because bile duct injuries are often unrecognized at the time of the index operation, definitive repair is often conducted remotely. Multiple reports suggest that surgical repair of these injuries is highly successful in both immediate and delayed cases (Lillemoe et al, 2000; Pekolj et al, 2013; Perera et al, 2011; Sicklick et al, 2005). Large, single-institution reports have demonstrated success rates as high as 98% with low rates of mortality, major morbidity, reoperation, and anastomotic leak. This includes more recent reports focused on repairs performed immediately (Pekolj et al, 2013; Perera et al, 2011). The most frequently used options for repair are hepaticojejunostomy (nearly ubiquitous in the delayed setting) and primary repair versus a T-tube. Multiple studies have shown that bile duct injuries should be managed by experienced hepatobiliary surgeons because repairs performed by nonhepatobiliary surgeons have significantly increased rates of morbidity and failure (Melton & Lillemoe, 2002; Perera et al, 2011; Stewart & Way, 1995). Surgical management of bile duct injuries and strictures is discussed in greater detail elsewhere in this text. Hemorrhage Several large series have defined the risk of perioperative bleeding in patients undergoing cholecystectomy. A Swedish registry study of 48,010 cholecystectomies found that bleeding necessitating transfusion, reoperation, conversion to open, and/or other measures prolonging hospital stay occurred in 2. In a retrospective analysis of 9542 consecutive laparoscopic cholecystectomies by Duca and colleagues (2003), intraoperative hemorrhage occurred in 224 patients, for an incidence of 2. This figure demonstrates complete clearance of the hepatocystic triangle, the presence of only two structures going into the gallbladder, and separation of the gallbladder from the lower one third of the cystic plate. Tangential lesions of the cystic artery or, less commonly, total sectioning of the cystic artery occurred in 95 out of 224 cases of bleeding. In the majority of cases, the intraoperative bleeding was controlled laparoscopically with hemostatic clips. Damage to the hepatic artery occurred in one instance and required immediate conversion to an open procedure. Finally, bleeding from the greater omentum was seen in 18 cases and controlled laparoscopically in 16 cases. Another source of massive intraoperative blood loss is from inadvertent incursion into a deep plane of hepatic parenchyma where distal tributaries of the middle hepatic vein may be encountered. In fact, 10% of patients harbor large branches of the middle hepatic vein directly adjacent to the gallbladder fossa, which may lead to significant hemorrhage in instances of even mild parenchymal dissection (Ball et al, 2006). It should be recognized that management of profuse bleeding during cholecystectomy can be fraught with significant ramifications. An autopsy study has demonstrated that approximately 7% of cadavers having undergone cholecystectomy had evidence of injury to the right hepatic artery or its branches (Halasz, 1991). Although this alone appears to be well tolerated, combined injuries to the right hepatic artery and bile duct harbor far more significant consequences (Stewart et al, 2004; Strasberg & Helton, 2011). By contrast, extreme vasculobiliary injuries involving injury to a portal vein, hepatic artery, and bile duct are most severe and often result in death (Strasberg & Gouma, 2012). When seen, these injuries have often occurred despite conversion to an open procedure. The surgeon must be cognizant of the fact that the anatomy of the hilum may be severely distorted in the face of severe inflammation, as the fundusdown technique has been used frequently in these cases. In these instances, it is often difficult to decipher whether the retained stones are a consequence of intraoperative gallbladder manipulation or incorrectly interpreted studies. The majority of infections in the open approach were seen in superficial spaces, whereas infections in the laparoscopic setting were less frequent but were more commonly in organ spaces. Neither perioperative antibiotic prophylaxis nor routine drainage improves the rate of infectious complications following cholecystectomy. That antibiotic prophylaxis carries no benefit in lower-risk patients undergoing elective cholecystectomy has been shown in multiple studies (Chang et al, 2006; Harling et al, 2000; Koc et al, 2003; Tocchi et al, 2000; Uludag et al, 2009). More recently, a gallstone surgery registry was used to demonstrate that prophylactic antibiotics also carry no benefit in acute cholecystectomy (Jaafar et al, 2014). This is because gallbladder spillage during open cholecystectomy is more easily controlled, and dropped gallstones are more likely to be identified and retrieved. Perforation of the gallbladder during laparoscopic cholecystectomy is more common and less controlled. Estimates of gallbladder perforation and stone spillage range from 6% to 40% in laparoscopic cholecystectomy (Brockmann et al, 2002; Helme et al, 2009; Schafer et al, 1998; Soper & Dunnegan, 1991). It can occur for many reasons, including excessive retraction during dissection, direct puncture with an instrument, and removal of a distended gallbladder through a trocar site. This, combined with increased difficulty in identifying and retrieving spilled stones, has dramatically increased complications from gallbladder perforation in the laparoscopic era. The most frequent complication of spilled stones is abscess-either intraabdominal or of the abdominal wall (Dobradin et al, 2013; Horton & Florence, 1998; Wilton et al, 1993; Zehetner et al, 2007). Stones have even been reported to erode into the chest cavity, causing empyema and broncholithiasis with expectoration. Although the spillage of gallstones is obviously an intraoperative event, complications of spilled gallstones can be termed a late technical issue in that they often materialize weeks to months after the procedure. Reoperation for morbidity from stone spillage has been reported as late as 15 years after cholecystectomy (Arishi et al, 2008; Gooneratne, 2010). Because complications from spilled stones are the exception rather than the rule, we do not recommend converting to an open procedure in the event of gallbladder perforation. However, efforts should be made to retrieve stones with suctioning, forceps, and irrigation. It is also a good policy to document the event and to inform the patient that stone spillage occurred in the event of latent complications and/or confounding imaging findings. Notably, spilled gallstones have even been noted to mimic hepatic and peritoneal metastases (Arai et al, 2012; Dasari et al, 2009; Rammohan et al, 2012). In this instance, it is sometimes difficult to delineate whether a stone has persisted in a long cystic duct remnant or whether there has been relapse of lithiasis in a gallbladder remnant. Many reports are surgical series and thus report only on patients in whom the finding has been managed surgically. However, anecdotal case reports suggest that incomplete gallbladder removal is more common in the laparoscopic than open era. This may partly reflect the prevalence of subtotal cholecystectomy in the era of minimally invasive surgery. Laparoscopic subtotal cholecystectomy technique was first reported in the early 1990s (Bickel & Shtamler, 1993) and has been shown to be relatively safe (Ji et al, 2006; Sharp et al, 2009). However, a systematic review of the technique used in this procedure shows that a number of surgeons purposefully leave behind a gallbladder pouch that often is sutured or stapled closed (Henneman et al, 2013). This tactic is contrary to that described for open subtotal cholecystectomy in which the posterior wall of the gallbladder is left attached to the liver and the cystic duct is secured at its origin with a purse-string technique (Bornman & Terblanche, 1985). Although the alternative laparoscopic approaches to subtotal cholecystectomy are more convenient, they do increase the risk of relapsing lithiasis. Resection of gallbladder and cystic duct remnants due to lithiasis has been achieved through both laparoscopic and open approaches. However, advanced endoscopic techniques carry the potential to manage this problem even less invasively (Benninger et al, 2004; Phillips et al, 2014). Phillips and colleagues (2014) recently described their institutional approach to remnant cystic duct lithiasis, which illustrates the potential for multidisciplinary management. Twelve patients were described, and the mean interval from cholecystectomy to discovery of remnant cystic duct stones was 34. Six of the 12 patients underwent reoperation, two of which were urgent due to acute cystic duct obstruction with inflammation. All of these procedures were begun laparoscopically but required conversion to open. These postsurgical strictures can also result from delayed thermal injury or intraoperative ischemic devascularization (Deziel et al, 1993; Genest et al, 1986). Strictures most commonly present with abdominal pain, fever, and jaundice due to mechanical obstruction. Over time, resultant cholestasis can ultimately lead to choledocholithiasis and recurrent cholangitis (Kassab et al, 2006). Endoscopic retrograde cholangiopancreatography cholangiogram shows a gallstone noted in a gallbladder remnant in this patient who had a history of a difficult cholecystectomy. However, many studies have more recently reported the safety and efficacy of endoscopic or percutaneous balloon dilation and/or stenting as a less invasive means of treating such problems (Gouma, 2007; Kassab et al, 2006; Vitale et al, 2008) (see Chapters 27, 29, and 30).

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This adjunctive maneuver seems easy to use and appears effective in the prevention of bile leaks treatment neuroleptic malignant syndrome cheap tolterodine 2 mg line. This may have a positive impact on postoperative infectious complications after hepatic resection but requires further validation medicine 7 order 2 mg tolterodine fast delivery. Regarding parenchymal transection techniques symptoms cervical cancer purchase on line tolterodine, no one method or combination of methods has been shown to be superior doctor of medicine order cheap tolterodine line. Therefore it is recommended that the surgeon use the technique that is most familiar treatment 6 month old cough order tolterodine once a day, while limiting the amount of necrotic liver parenchyma left behind (Yanaga et al, 1986). We also believe that it is important to suction any pooled blood and bile at the end of the operation (see Chapter 103). The use of absorbable suture material versus silk during hepatectomy has also been studied with regard to infectious complication. However, a prospective randomized controlled trial found no difference between silk and Vicryl suture with regard to infection (Harimoto et al, 2011). Perioperative Antibiotics the Clinical Practice Guidelines for Antimicrobial Prophylaxis published in the American Journal of Health-System Pharmacy (Bratzler et al, 2013) represent the most current recommendations on preoperative antimicrobial prophylaxis. The guidelines, however, do provide recommendations on biliary tract procedures, including cholecystectomy, exploration of the common bile duct, and choledochoenterostomy. The guidelines state that the most common organisms associated with infection after these particular procedures include Escherichia coli, Klebsiella species, and enterococci. The recommended antibiotic for open biliary tract surgery is cefazolin; alternative agents are ampicillin-sulbactam, cefotetan, cefoxitin, and ceftriaxone. It is important to note, however, that none of the cephalosporins cover enterococci (see Chapters 12, 29, and 30). As mentioned earlier, the recommended antimicrobial agent for biliary tract procedures from the Clinical Practice Guidelines for Antimicrobial Prophylaxis is cefazolin. However, we typically broaden our preoperative coverage with a second-generation cephalosporin or a carbapenem. We currently favor ertapenem because it is a single agent with broad coverage, dosed daily. Whatever agent is used, it should be given within 60 minutes of skin incision and redosed appropriately intraoperatively to maintain adequate tissue levels. Half of the patients received postoperative antibiotics, whereas the other half did not. The authors concluded that postoperative antibiotic prophylaxis cannot prevent postoperative infections after liver resection. Regarding liver surgery specifically, this paper suggests that surgical drains do not necessarily prevent biloma formation and do not always prevent the need for percutaneous drainage. A grade A recommendation was given against prophylactic drainage in elective hepatic resection. This is supported by several randomized studies (Belghiti et al, 1993, Fong et al, 1996, Liu et al, 2004) and a systematic review (Gurusamy et al, 2007). A more recent multicenter international prospective study also concluded that intraoperatively placed surgical drains do not prevent the need for additional percutaneous drainage (Brooke-Smith et al, 2015). Postoperative Risk Mitigation Nasogastric Decompression Pessaux and colleagues (2007) conducted a randomized clinical trial examining the utility of postoperative nasogastric decompression after elective hepatectomy. The authors randomized 200 patients to nasogastric tube use versus no nasogastric tube. The use of a nasogastric tube was significantly associated with an increased rate of pneumonia and atelectasis but did not reduce overall surgical complications, medical morbidity, in-hospital mortality, duration of ileus, or length of hospital stay. Early Enteral Nutrition and Synbiotics the concept of early enteral nutrition has been studied in patients undergoing liver resection. Richter and colleagues (2006) conducted a systematic review of early enteral nutrition following open liver resection, concluding that it is safe and that it decreases the incidence of postoperative complications in comparison to parenteral nutrition. The authors noted a statistically significant lower rate of wound infections and catheterrelated infections with early enteral feeding versus parenteral nutrition. However, pneumonias and intraabdominal abscesses were not significantly decreased. It should be noted that enteral nutrition in this review was, in general, started on the second postoperative day via an operative jejunal tube. We do not advocate placement of jejunal feeding catheters in the otherwise healthy liver resection patient. However, for the malnourished patient, early enteral nutrition perhaps via a planned jejunal tube is recommended over parenteral nutrition. Enteral nutrition supports gut-barrier function, mitigating the risk of bacteremia originating from the enteric system (Mizuno et al, 2010). However, a perturbation in the microbial balance within the intestinal lumen can also pave the way for infections after liver surgery. Synbiotic therapy, which is a combination of probiotic and prebiotic therapy, has been studied as a method of potentially reducing infectious morbidity after liver surgery. Probiotics are defined as live bacteria that are capable of improving the microbial balance within the intestinal lumen. Several studies have documented encouraging results in the ability of synbiotic therapy to help prevent postoperative infectious complications after liver surgery, especially in patients with biliary cancer (Kanazawa et al, 2005; Sugawara et al, 2006; Usami et al, 2011). Nakayama and colleagues (2014) evaluated the utility of subcutaneous drains in the prevention of wound infection. After fascial closure, a 10 Fr drain connected to negative pressure was placed in the subcutaneous tissue. The rationale for leaving an intraabdominal drain is to detect and prevent biloma formation in the event of bile leakage after hepatic resection. Bile leakage and subsequent biloma formation is an important contributor to infectious complications after hepatic resection, as stated earlier. However, the overall trend reflected in the literature does not support the use of drains in elective hepatic surgery. Pancreatic Resection the location and nature of disease within the pancreas dictates the specific type of pancreatic resection used. With modern imaging modalities, resection type can often be determined preoperatively. The most commonly performed resections include pancreaticoduodenectomy and distal pancreatectomy (typically with splenectomy when performed for cancer); hence the studies of infectious complications after pancreatectomy focus on these two procedures. For pancreaticoduodenectomy, organ/space infection can be further categorized by the contributing anastomosis: intraabdominal abscesses, or infected fluid collections can be related to an infected bile, pancreatic, or enteric leak, or a combination of these. Organ/space infection after distal pancreatectomy is typically related to pancreatic leak. As with any major abdominal operation, these patients are also at risk for the development of abscesses not related to anastomotic leakage or secondary to an infected hematoma. Furthermore, these patients can develop remote-site infections, including bloodstream infections, cholangitis, respiratory tract infections, urinary tract infections, and Clostridium difficile infections. These are presented according to each stage of patient care: preoperative, intraoperative, and postoperative. In many instances, it may not be possible to significantly modify risk; nonetheless, it is important to understand potential risk factors so that the patient can be monitored with the appropriate degree of vigilance in the postoperative period. Blood Glucose Control Since the landmark paper by van Den Berghe and colleagues (2001) demonstrating improved outcomes with intensive insulin therapy, there has been much focus on tight blood glucose control in the surgical patient. Huo and colleagues (2003) demonstrated increased hepatic decompensation in diabetic patients undergoing hepatic resection for hepatocellular carcinoma. Little and colleagues (2002) showed an association with increased mortality in diabetic patients undergoing hepatectomy for colorectal cancer metastasis. Methods of glycemic control include sliding scales and continuous insulin infusions; however, other less conventional approaches have been used. Promising results have also been obtained with the hyperinsulinemicnormoglycemic clamp technique. This method was shown to reduce complications, including infections after hepatectomy in a study by Fisette and colleagues (2012). Preoperative Biliary Drainage in the Hilar Cholangiocarcinoma Patient (See Chapters 27 and 51) Preoperative biliary drainage before hepatic resection for extrahepatic hilar cholangiocarcinoma is a crucial consideration when anticipating the surgical approach and postoperative outcomes. Postoperative outcomes after liver resection tend to be worse in patients with obstructive jaundice (Belghiti et al, 2000). Preoperative biliary drainage was therefore initially commonplace before the performance of elective liver resection for obstructed patients with hilar cholangiocarcinoma. However, the procedure is associated with preoperative cholangitis, and relatively recent literature has confirmed that it is also associated with increased postoperative complications, infectious complications in particular (Ferrero et al, 2009; Hochwald et al, 1999). This has called into question whether or not routine preoperative biliary drainage should be performed in hilar cholangiocarcinoma patients undergoing hepatic resection. In fact, a recent review by Liu and colleagues (2011) concluded that preoperative drainage should not be routinely performed. House and colleagues (2008) studied postoperative complications in 356 patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma with the goal of identifying preoperative patient and radiographic factors associated with postoperative morbidity. Complications developed in 38% of this patient population, with the most common pancreatic fistula/abscess, wound infection, and delayed gastric emptying. The authors also determined that the degree of visceral fat as seen on preoperative axial imaging correlated with higher rates of overall complications and pancreatic fistula. Chapter 12 Infections in hepatic, biliary, and pancreatic surgery 213 complications. Nineteen perioperative variables were studied in an effort to determine which predicted infectious morbidity. The authors examined preoperative factors that might predict perioperative morbidity and mortality. Although this study was not designed to predict who would incur an infectious complication specifically, the authors found that the most frequent complications after pancreaticoduodenectomy included sepsis (15. Other predictors included older age, male gender, dependent functional status, chronic obstructive pulmonary disease, steroid use, bleeding disorder, leukocytosis, elevated serum creatinine, and hypoalbuminemia. Kelly and colleagues (2011) attempted to identify preoperative and operative risk factors for the development of complications after distal pancreatectomy. Their efforts concerned the development of a risk score for patients undergoing distal pancreatectomy. Similar to the analysis conducted by Greenblatt and colleagues (2011), this study was not designed to specifically address infectious complications. The other preoperative variables associated with postoperative complications included male gender, smoking, steroid use, neurologic disease, preoperative systemic inflammatory response syndrome /sepsis, hypoalbuminemia, elevated creatinine, and abnormal platelet count. La Torre and colleagues (2013) noticed a relationship between malnutrition and morbidity after pancreatic surgery in their retrospective evaluation of data collected from 143 patients undergoing pancreatic resection for cancer. The authors then conducted a multivariate regression analysis on just preoperative and intraoperative risk factors (excluding the postoperative development of pancreatic fistula). As noted above, modification of the aforementioned preoperative risk factors may be difficult or even impossible prior to pancreatectomy. This is particularly true if the indication for resection is cancer or suspicion of cancer, which is common. In these instances, proceeding to the operating room expeditiously may be the prudent course of action, especially in the clearly resectable and otherwise healthy operative candidate. However, more than one-third of patients about to undergo pancreaticoduodenectomy can be considered borderline candidates from a medical standpoint (Tzeng et al, 2014). These patients are at significant risk for postoperative morbidity (including infectious complications) as well as mortality. Therefore, as suggested by Tzeng and colleagues, surgeons should strongly consider improving the condition of the patient to mitigate infectious/ overall morbidity and mortality in these "borderline resectable type C" patients before surgery. For patients seen with surgically resectable tumors but significant reversible functional deficits, it may be worthwhile to administer neoadjuvant therapy while the patient is medically optimized. Regardless of whether neoadjuvant therapy consists of chemoradiation or chemotherapy alone, either type of preoperative therapy is considered safe with regard to postoperative complications (Araujo et al, 2013; Cheng et al, 2006; Cho et al, 2014; Heinrich et al, 2008). Preoperative Biliary Drainage Preoperative biliary drainage in the setting of an obstructing pancreatic head mass continues to be debated. Earlier studies suggested that perioperative mortality is higher when pancreaticoduodenectomy is performed on the hyperbilirubinemic patient (Bottger et al, 1999; Braasch et al, 1977; Lerut et al, 1984) (see Chapters 29, 30, and 66). More recent work has also shown preoperative jaundice to be a poor prognostic factor with regard to overall survival for patients undergoing resection of the head of the pancreas for adenocarcinoma (Strasberg et al, 2014). However, the literature continues to suggest that attempts at normalizing the bilirubin preoperatively may have detrimental effects that manifest in the postoperative period. Healthy patients with an intact sphincter of Oddi and a normal biliary system have sterile bile for all of the reasons discussed previously. However, obstructive jaundice in the setting of a mass in the head of the pancreas results in bile stasis. This in turn promotes colonization of the biliary system, especially after the bile ducts are interrogated and drained via stents (Limongelli et al, 2007). When normal host defense mechanisms present in the liver and biliary tree are overwhelmed by a critical level of bacterobilia and the biliary tree is not adequately drained, then pathogenic enteric organisms may reach the systemic circulation through the liver, causing sepsis. It is rare for a patient with pancreatic cancer to be seen with cholangitis without having undergone attempts at biliary decompression. In the United States, typical drainage procedures include decompression via the percutaneous transhepatic approach or via endoscopic retrograde cholangiography. More commonly, cholangitis develops during or soon after attempted biliary decompression in the patient who is undergoing elective preoperative biliary drainage. Unfortunately, these patients who develop cholangitis preoperatively are at increased risk for postoperative complications, especially those related to infection (Kitahata et al, 2014; Kondo et al, 2013) (Table 12. The mere presence of bacterobilia, often related to preoperative biliary drainage, increases the risk of infectious complications in the postoperative setting (Cortes et al, 2006; di Mola et al, 2014; Howard et al, 2006; Jagannath et al, 2005; Lermite et al, 2008; Limongelli et al, 2007; Povoski et al, 1999a, 1999b; Sivaraj et al, 2010) (see Table 12. Therefore preoperative biliary drainage in the resectable patient should be given thoughtful consideration, especially in light of a recent multicenter, randomized trial that showed routine preoperative biliary drainage increases the rate of postoperative complications in general (van der Gaag et al, 2010).

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