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Complications - Anastomosis technique, biliodigestive, according to Hepp-Couinaud

general and visceral surgery
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Intraoperative Complications

    • Injury to the bile ducts > Suture, possibly bile duct drainage
    • Injury to the hepatic artery or its branches > End-to-end anastomosis, possibly patch
    • Bowel injury > Oversewing

  2. Postoperative Complications

    • Postoperative bleeding > usually within the first 24 hours > immediate re-exploration with identification of the bleeding source and secure control of the bleeding.
    • Cholangitis > antibiotic treatment
    • Biliary obstruction (fever, jaundice, pain) > normal in the first days due to postoperative edema; in case of persistent obstruction, stent via ERCP or PTC; re-establishment of the anastomosis no earlier than 6-8 weeks.
    • Pancreatitis > conservative treatment
    • Delayed gastric emptying/ileus > often indirect signs of peritonitis > CT; caution aspiration!
    • Insufficiency of the biliodigestive anastomosis >

    * Stable patient without signs of peritonitis > leave target drainage in place, monitor output, further diagnostics via CT, possibly MRCP.
    * Suspected peritonitis > revision with placement of an enterohepatic drainage and oversewing; re-establishment of the anastomosis rarely indicated.

    An algorithm for the management of bile fistulas can be found here: Bile Fistula

    • Insufficiency of the small bowel anastomosis >

    * Discharge of small bowel secretions through the wound, suspicious drainage fluid, i.e., either clearly small bowel secretions or fluid with increased bilirubin or amylase concentration compared to serum, oral administration of toluidine blue solution and its discharge through the existing target drainage.
    * Already removed drainages: sonographically or CT-guided puncture, possibly with drainage.
    * An MDP or a CT with water-soluble contrast medium cannot reliably exclude a leak of a small bowel anastomosis!
    * Enterocutaneous fistulas, especially originating from the blind end of the jejunum, can be treated conservatively.
    * The clinical assessment of the patient is crucial: pain with signs of local or generalized peritonitis, signs of sepsis with an increase in infection parameters in the laboratory > even with inconclusive diagnostics, prompt decision for relaparotomy!

    An algorithm for the management of small bowel fistulas can be found here: Small Bowel Fistula

    • Stenosis as a late complication with intermittent cholangitis > stent, possibly re-establishment