1. science
2. medicine
3. surgery

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TECNOLOGIA E TECNICA OPERATORIA/
TECHNOLOGY AND SURGERY TECHNIQUE
How to improve biliostasis
in liver surgery
ANTONIO FRENA, FEDERICO MARTIN
Chirurgia 2 - Dipartimento di Chirurgia Generale 2 - Ospedale Regionale di Bolzano
Correspondence to: Dr. Antonio Frena - Chirurgia 2 - Ospedale Regionale - Via Lorenz Böhler, 5 - 39100 Bolzano
(Italy)
Riassunto
Una delle complicazioni più temute dopo resezione epatica rimane la fistola biliare. Nel corso della nostra esperienza abbiamo testato molti materiali atti a coadiuvare il chirurgo nella prevenzione di questa complicanza. In questo articolo
analizziamo i risultati ottenuti a partire dal 2005 utilizzando una spugna medicata
di collagene rivestito di fibrinogeno e trombina (Tachosil ®). La fistola biliare si è
verificata nel 3.9% dei casi di resezione elettiva e nel 5.1% dei casi di emostasi per
trauma epatico. I buoni risultati sembrerebbero indicare che il chirurgo epato-biliare può contare su un emo-biliostatico locale di discreta efficacia.
Parole chiave: chirurgia epatica, biliostasi, spugna di collagene
Summary
How to improve biliostasis in liver surgery. A. Frena, F. Martin
One of the most fearful complications following hepatic resection is the onset of a
biliary fistula. We have attempted to improve intraoperative biliostasis to minimize
the risk of postoperative fistula development by testing different materials. In the
early 2005 we began employing a collagen sponge coated with fibrinogen and
thrombin (Tachosil ®). In our clinical experience, prior to sponge use, a biliary fistula developed in 3.9% of elective resections and 5.1% of surgical procedures for
liver trauma. Until now there were no postoperative bile leaks in the patients treated with Tachosil.
Key words: liver surgery, biliostasis, collagen sponge
Chir Ital 2006; 58, 6: 793-795
During the last two decades, standardisation of hepatic resective
treatment has significantly reduced mortality and morbidity
rates1. Anatomical resection, the
use of a standardised technique or
of manoeuvres such as the hanging manoeuvre, and increasingly
effective haemostasis led to a reduction in postoperative complication rates (4-7%)2. Despite these
advances, one of the most feared
complications following hepatic
resection is the occurrence of a
biliary fistula, namely bile leakage
through small lesions in the biliary
ductules following parenchymal
transection. Although numerous
intraoperative methods for the detection of bile leaks – from injection of methylene blue dye in the
cystic duct to assessment of white
pads placed on the transected surface – were developed in practice
and chemical substances such as
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Chirurgia Italiana
TECNOLOGIA E TECNICA OPERATORIA/
TECHNOLOGY AND SURGERY TECHNIQUE
sealants and celluloses 3 were
manufactured for fistula management, the problem of biliostasis is
still debated worldwide. This is
demonstrated by the numerous
techniques described in the international literature, yielding a large
amount of data from which it is
difficult to extrapolate methodological and/or clinic evidence
due to their lack of homogeneity.
Our experience with hepatic resection began in 1995.We have attempted to improve intraoperative biliostasis in order to minimise the risk of postoperative fistula development by testing different materials.
Finally,in early 2005,we began employing a collagen sponge coated
with fibrinogen and thrombin
(Tachosil®). This is a medicinal
product which was recently introduced on the Italian market. Its efficacy in second-level haemostasis
(following primary haemostasis
achieved with stitch and clip
placement) has already been tested in international controlled
studies4. Before applying the product, the resected surface must be
cleaned of blood and other fluids
and subsequently the sponge,
moistened with saline solution,
can be applied, gently pressing for
3-5 minutes (Fig. 1). We advocate
application using a moist pad to
avoid the sponge from sticking to
the surgeon’s gloves.
In our clinical experience,prior to
sponge use, a biliary fistula developed in 3.9% of elective resections (4/103 cases) and 5.1% of
surgical procedures to treat bleeding due to hepatic trauma (4/79
cases)5. In contrast, there were no
postoperative bile leaks in the 14
patients (11 hepatic resections
and 3 traumas) treated with the
collagen sponge coated with fib-
794
2006 - vol. 58 n. 6 pp 793-795
Fig. 1. The sponge is applied on the resected surface
following right hemihepatectomy for colorectal carcinoma
metastases.
a
b
Fig. 2. Following removal of the caudate lobe and
tangential resection of the vena cava (a) for colorectal
carcinoma metastases the sponge is applied (b) on the
resected surface.
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How to improve biliostasis in liver surgery
rinogen and thrombin, and the
drain was always removed 3-5
days after surgery. Although the
limited number of cases do not
constitute clinical evidence, it
should be noted that hepatobil-
iary surgeons can rely on local
products for haemo- and biliostasis, enabling them to carry out hepatic resection safely (Fig. 2) or
post-traumatic liver haemostasis.
Reduced or zero incidence of bil-
iary fistula has a positive impact
on both patients (lower septic
complication and re-operation
rates) and institutions (shorter
mean hospital stay and reduced
costs).
Bile leakage after hepatic resection. Ann
Surg 2001; 233: 45-50.
MFA, Broelsch CE. Effectiveness of a new
carrier-bound fibrin sealant versus argonbeamer as haemostatic agent during liver resection: a randomised prospective trial. Langenbecks Arch Surg 2005; 390: 114-20.
References
1. Jarnagin WR, Gonen M, Fong Y, DeMatteo R, Ben-Porat L, Little S,
Corvera C, Weber S, Blumgart L. Improvement in perioperative outcome
after hepatic resection. Analysis of
1803 consecutive cases over the past
decade. Ann Surg 2002; 236: 397407.
2. Yamashita Y, Hamatsu T, Rikimaru T.
3. Petelenz K, Rubin J. Fibrin Sealants:
valuable asset or just an additional expense. Curr Surg 2005; 62: 400-4.
4. Frilling A, Stavrou GA, Mischinger HJ, de
Hemptinne B, Rokkjaer M, Klempnauer J,
Thoerne A, Gloor B, Beckebaum S, Ghaffar
5. Martin F, Frena A, La Guardia G, Catalano P. Indicazioni e risultati delle prime
100 resezioni epatiche a Bolzano. Chir
Ital 2004; 56: 11-21.
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SOCIETÀ ITALIANA
DI CHIRURGIA
109° CONGRESSO
Verona
14-17 ottobre 2007
Centro Congressi Verona Fiere
Presidenti:
Claudio Cordiano
Vincenzo Pezzangora