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( Saurabh Galodha ),( Rajneesh K Singh ),( Rajan Saxena ),( V K Kapoor ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1
Aims: Post cholecystectomy biliary strictures can lead to secondary biliary cirrhosis and portal hypertension and present a difficult proposition for management with poorer outcomes. These patients require a major hepatic resection (HR) in certain cases. This study was done to find the factors leading to HR in benign biliary strictures (BBS), the challenges faced and their long-term outcomes. Methods: Analysis of prospectively maintained BBS database of our department from February 1989 to March 2014 done to identify patients who underwent HR. Type of cholecystectomy, bile duct injury (BDI) and BBS, indications for HR, any previous repair, intraoperative parameters and postoperative morbidity were noted. Outcomes classified according to McDonald classification. Results: 648 patients of BBS were included in the study. Out of these 10 patients underwent HR (1.53%). 9 patients had high BBS (type IV and V) while 1 patient was of type III with strictured hepaticojejunostomy (HJ). Laparoscopic cholecystectomy was the primary surgery in 80%(8/10) patients. Median time from cholecystectomy to HR was 545 (226-1566) days. Proximal BBS (type IV and V, P<0.001) and Atrophy-hypertrophy complex (AHC) (P=0.004, OR = 15.4, CI: 2.94-80.99) were predictive factors for HR. Failed previous repair was also associated with HR (20%). Postoperative morbidity was 40%. Perioperative mortality occurred in 2 patients. Outcomes of HR with median follow up of 24 months were good with success rate of 80%. Conclusions: Hepatic resections have distinct role in patients of proximal BBS (type IV and V) with AHC with good long-term results but require meticulous planning and execution. AHC and previous failed repair are strong predictors for need for HR in BBS.
( Saurabh Galodha ),( Rajneesh K Singh ),( Anu Behari ),( Ashok Kumar Gupta ),( V K Kapoor ),( Rajan Saxena ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1
Aims: Portal hypertension (PHT) and secondary biliary cirrhosis (SBC) are found in 7-20% patients of postcholecystectomy benign biliary strictures (BBS), which can lead to significant morbidity and mortality. This study was done to look for factors associated with PHT and SBC in BBS and its effect on perioperative morbidity and final outcomes. Methods: A retrospective analysis of 613 patients of BBS managed between January 1989 and December 2012 was done. Preoperative and intraoperative parameters and perioperative morbidity were registered. Outcomes were analyzed with McDonald grading with grades A and B considered as success. Results: A retrospective analysis of 613 patients of BBS managed between January 1989 and December 2012 was done. Preoperative and intraoperative parameters and perioperative morbidity were registered. Outcomes were analyzed with McDonald grading with grades A and B considered as success. Nineteen patients of BBS with PHT were operated. PHT was seen more commonly in BBS grade III and above (n=12,63%). The median time to repair in patients with PHT was more than 4 times that of patients without PHT (826 days vs. 210 days). Two patients with PHT had strictured previous primary repair in the form of Roux-en Y hepaticojejunostomy (RYHJ). In all patients RYHJ with liver biopsy was performed. None of the patients required prior portosystemic shunting. In patients with PHT mean operating time (4.6 ± 2.8 vs. 3.5 ± 2 hours) as well as median blood loss (400 ml vs. 200 ml) was increased but there was no significant increase in perioperative morbidity. Median follow up for these patients was 54 months. Success rate for RYHJ was 89% and only 1 patient required a revision RYHJ due to stricture and recurrent cholangitis. Conclusions: Delayed repair, higher grade of BBS and failed primary repair are factors associated with development of PHT in BBS. RYHJ is feasible without need of portosystemic shunting in all these patients with minimal morbidity and good long-term results.
Non Hepatic Surgery in Cirrhotic Patients: 10 Year Experience - Vision Beyond Nihilism
( Saurabh Galodha ),( Waliullah Siddiqui ),( Jacob Mathew ),( John Mathew ),( Manipadam ),( Abhishek Yadav ),( Mahesh S,H Ramesh ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1
Aims: Non hepatic surgery in cirrhotic patients has been viewed with a feeling of nihilism with reported in hospital mortality rates of 8-25%. In this study we look for risk factors associated with increased morbidity and mortality and present a positive perspective for these patients. Methods: A retrospective analysis of patients with cirrhosis undergoing nonhepatic surgery during the period from January 2007 to December 2016 was done. Child Turcot Pugh (CTP) and MELD scores, intraoperative parameters, perioperative morbidity (Clavien Dindo classification) and mortality and hospital stay was recorded. Results: 193 patients with cirrhosis underwent non-hepatic surgery. 88 patients (45%) had biliary pathology. Other groups were gastroduodenal (n=20,10%), pancreatic (n=13,6.7%), colorectal (n=15,7.5%) and hernia (n=13,6.7%). 38 patients (19.6%) underwent surgery for malignancy. Emergency surgery was done in 6 patients. 133 patients had CTP grade A while 49 patients grade B and 11 patients had grade C. Mean MELD score was 8.5 ± 5.2. Overall mean operating time was 3.1 ± 1.1 hours with mean blood loss of 105 ± 40 ml while in those undergoing major surgery (Frey’s procedure, pancreaticoduodenectomy, colorectal resections, gastrectomy) operating time was 4.5 ± 2.6 hours and blood loss was 335 ± 130 ml. Median blood transfusion requirement was 2 (1-5) PRBC in these patients. Major morbidity (Clavien Dindo > 3) was seen in 11 patients (5.6%) with majority having CTP grade C (n=6,55%). Perioperative mortality occurred in 2 patients (1%). Patients undergoing surgery in emergency had more morbidity (n=2,33%) and mortality (n=1,16%). Conclusions: In cirrhotic patients undergoing non-hepatic surgery factors associated with poor outcomes are emergency surgery, higher CTP grade and MELD score. We need to shun nihilistic attitude in these patients as better preoperative optimization and meticulous surgery lead to very good outcomes.
Rajan Saxena,Nalini Kanta Ghosh,Saurabh Galodha 한국간담췌외과학회 2021 Annals of hepato-biliary-pancreatic surgery Vol.25 No.4
Backgrounds/Aims: Hepaticojejunostomy (HJ) for bilioenteric continuity is generally performed with interrupted sutures. This study compares the safety, economics, short- and long-term outcomes of continuous suture hepaticojejunostomy (CSHJ) and interrupted suture hepaticojejunostomy (ISHJ). Methods: A retrospective cohort analysis involving all HJs between January 2014 and December 2018 was conducted. Patients with type IV or V biliary strictures, duct diameter < 8 mm and/or associated vascular injury, and liver transplant recipients were excluded. Patient demographics, preoperative parameters including diagnosis, intra-operative parameters including type and number of sutures, suture time, and postoperative morbidity (based on Clavien-Dindo classification) were recorded. Patients were followed up to 60 months. McDonald’s Grade A and B outcomes were considered favorable. Cost according to suture type and number (polydioxanone 3-0/5-0 mean cost, US$ 9.26/length; polyglactin 3-0/4-0 mean cost, US$ 6.56/length), and operation room charge (US$ 67.47/hour) were compared between the two techniques. Statistical analysis was performed using IBM SPSS ver. 22 software. Results: A total of 556 eligible patients (468 patients undergoing ISHJ and 88 undergoing CSHJ; 47% [n = 261] with malignant and 53% [n = 295] with benign pathology) were analyzed. The two groups were similar. Number of sutures, cost, time, and postoperative bile leak were significantly higher in the ISHJ group. Bile leak occurred in 54 patients (6 CSHJ, 48 ISHJ). Septic shock-induced death occurred in 16 cases (3 CSHJ, 13 ISHJ). Morbidity and the anastomotic stricture rates were comparable in both groups. Conclusions: CSHJ is a safe, economical, and worthy of routine use.